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Nsevus Lipomatodes. 

(From a Photograph of one of the author's patients.) 



A PRACTICAL TREATISE 



ON 



DISEASES OF THE SKIN 



FOR THE USE OF 

STUDENTS AND PRACTITIONERS 

TSYy 

JAMES NEVINS HYDE, A.M., M.D. 

» » 
PROFESSOR OF SKIN, GENITOURINARY, AND VENEREAL DISEASES, RUSH MEDICAL COLLEGE, 
CHICAGO; DERMATOLOGIST TO THE PRESBYTERIAN, AUGUSTANA, AND MICHAEL 
REESE HOSPITALS OF CHICAGO; AND CONSULTING DERMATOLOGIST TO 
THE CHICAGO HOSPITAL FOR WOMEN AND CHILDREN; 

AND 

FRANK HUGH MONTGOMERY, M.D. 

ASSOCIATE PROFESSOR OF SKIN, GENITO-URINARY, AND VENEREAL DISEASES, RUSH MEDICAL 
COLLEGE, CHICAGO ; PROFESSOR OF SKIN AND VENEREAL DISEASES, CHICAGO 
CLINICAL SCHOOL ; ATTENDING PHYSICIAN FOR SKIN AND VENE- 
REAL DISEASES, ST. ELIZABETH HOSPITAL, CHICAGO 

SIXTH AND EEVISED EDITION 



ILLUSTRATED WITH 107 ENGRAVINGS AND 27 PLATES IN COLORS 

AND MONOCHROME 




LEA BROTHERS & CO. 

PHILADELPHIA AND NEW YORK 

1901 



THE LIBRARY OF 


CONGRESS, 


Two Copies 


Received 


MAY. 10 


1901 


Copyright 


ENTRY 


CLASS O/XXc Urn. 


<?/ C 


7 


COPY 


B. 






Entered according to Act of Congress, in the year 1901, by 

LEA BROTHERS & CO., 

In the Office of the Librarian of Congress, at Washington. All rights reserved. 



• • • 

r> ( I C t t 



C i " '■ 



ELECTRCTYPED BY 
WfeSTOOTT & THOMSON, PHILADA. 



TO 

JAMES CLARKE WHITE, M. D. 

PROFESSOR OF DERMATOLOGY 
HARVARD UNIVERSITY 

FIRST PRESIDENT OF THE 

AMERICAN DERMATOL.OG-IGAL ASSOCIATION 
THIS TREATISE IS 

WITH HIS PERMISSION 
INSCRIBED 



PREFACE TO THE SIXTH EDITION. 



The rapid exhaustion of the Fifth Edition of this work has neces- 
sitated a revision at a date earlier than was anticipated. Among the 
subjects that have been wholly or in part rewritten for this Sixth 
Edition are : Anatomy, General Diagnosis, Herpes Simplex, Herpes 
Zoster, Acne, Psoriasis, Scleroderma, Tuberculosis, Blastomycosis, and 
Carates. Minor changes and additions have been made wherever 
necessary to place the work abreast of the most recent developments 
in dermatology. 

Three new plates and some new engravings have been added. 

In this, as in the preceding edition of the treatise, the names of 
authors mentioned in the text refer to their latest editions. 



PUBLISHERS' NOTE. 



The history of this work is one of growing appreciation and success. 
Its first edition appeared in 1883, the second in 1888, the third in 
1893, the fourth in 1897, the fifth toward the close of 1899, and the 
sixth early in 1901. One year has, accordingly, sufficed to exhaust a 
larger edition than was ever before published, and has again brought 
to the authors the opportunity of revising their work thoroughly to 
date, as they had done on every previous occasion. This standard 
treatise has come to be regarded as a source of information Avhich can 
be trusted to give always the best and latest knowledge of practical 
dermatology. 



CONTENTS. 



PAGE 

Anatomy and Physiology of the Skin 17 

General Symptomatology 51 

General Etiology 63 

General Pathology 70 

General Diagnosis 72 

General Prognosis 82 

General Therapeutics 84 

Classification 109 



DISEASES OF THE SKIN. 

CLASS I. 

DISOEDEES OF THE GLANDS. 

1. Of the Sweat-glands Ill 

Hyperidrosis . Ill 

Sudamen , 115 

Miliary Fever 116 

Hydrocystoma 117 

Anidrosis 118 

Bromidrosis 119 

Chromidrosis 120 

Uridrosis 122 

Haematidrosis 123 

Hidradenitis Suppurativa 123 

2. Of the Sebaceous Glands 124 

Seborrhoea 124 

Asteatosis . 136 

Comedo 137 

Milium 142 

Steatoma 144 

Congenital Fibro-sebaceous Disease 145 

Painless Dermoid Cysts 146 

Eare Consequences of Sebaceous Cystic Disease 146 

CLASS II. 

INFLAMMATIONS. 

Exanthemata . 147 

Morbilli 147 

Eotheln 151 

Scarlatina 152 

Variola 157 

Varicella 165 

Vaccinia 167 

ix 



x CONTENTS. 

PAG* 

Erythma 171 

Symptomatic Erythema 174 

Erythema Scarlatiniforme 175 

Erythema Pernio 176 

Erythema Intertrigo 177 

Erythema Multiforme 18C 

Herpes Iris 184 

Erythema Nodosum 185 

Pellagra 186 

Acrodynia 187 

Urticaria 188 

Urticaria Pigmentosa 196 

Angioneurotic (Edema 198 

Dermatitis 200 

Traumatica 200 

Venenata 201 

Calorica 204 

Congelatio 206 

Medicamentosa 207 

Eeigned Eruptions 216 

Gangrenosa 217 

Chronic Pustular, etc 217 

Symmetrical Gangrene, etc. (Raynaud's Disease) 219 

Erysipelas 220 

Erysipeloid 226 

Eurunculus 226 

Carbunculus 229 

Anthrax . 233 

Equinia 235 

Dissection-wounds and Animal Poisons 236 

Delhi Boil 237 

Phlegmone Diffusa 239 

Sycosis 240 

Impetigo 247 

Contagiosa ... 248 

Ecthyma 251 

Conglomerate Pustular Folliculitis 253 

Folliculitis and Perifolliculitis 254 

Herpes Simplex 255 

Herpes Zoster ■ 258 

Dermatitis Herpetiformis , 265 

Herpes Iris 266 

Pompholyx • 269 

Psoriasis 271 

Pityriasis rosea 289 

Dermatitis Exfoliativa 290 

Dermatitis Exfoliativa Infantum 292 

Pityriasis Rubra 293 

Pityriasis Rubra Pilaris 296 

Epidemic Exfoliative Dermatitis 298 

Parakeratosis Variegata 300 

Lichen Ruber 300 

Lichen Planus 304 

Lichen Annularis 309 



CONTENTS. xi 

PAGE 

Lichenification 310 

Eczema 310 

Topical and Special Varieties 356 

Of Children 356 

Of the Scalp , . 357 

Of the Face 359 

Of the Lips . 361 

Cheilitis Glandularis, etc 362 

Of the Nostrils 363 

Of the Ears 363 

Of the Eyelids 365 

Of the Beard 366 

Of the Genital Organs 367 

Of the Anus and Anal Kegion 370 

Of the Nipple and Breast of Women 372 

Of the Umhilicus 373 

Of the Thighs 373 

Of the Hands and Feet 375 

Of the Nails 378 

Universal 379 

Of the Tropics 379 

Eczema Seborrhceicum 381 

Dermatitis Repens 387 

Prurigo 387 

Acne 391 

Acne Rosacea 404 

Acne Varioliformis 409 

Impetigo Herpetiformis 411 

Pemphigus . . 412 

Acute 414 

Chronic 414 

Foliaceus 416 

Neonatorum 417 

Of Young Girls 417 

Vegetans 418 

Hydroa 423 

Vacciniforme 424 

^Estivale 425 

Epidermolysis Bullosa Hereditaria 426 

CLASS III. 

HEMORRHAGES. 

Purpura 429 

Simplex 430 

Rheumatica 430 

Hemorrhagica 432 

Scorbutica 432 

CLASS IV. 

HYPERTROPHIES. 

Lentigo 435 

Chloasma 436 



xn CONTENTS. 

PAGE 

Anomalous Discoloration 439 

Keratosis 442 

Pilaris 442 

Senilis 445 

Follicularis 445 

Keratodermia Palmaris et Plantaris 448 

Angiokeratoma 449 

Keratosis Follicularis Contagiosa ,. 450 

Hyperkeratosis Striata et Follicularis 451 

Parakeratosis Scutularis 451 

Parakeratosis 451 

Molluscum Epitheliale 452 

Callositas 456 

Callositas with Complications 457 

Clavus 457 

Cornu Cutaneum 459 

Verruca 460 

Multiple Cutaneous Tumors, Pruritic 465 

Synovial Lesions of the Skin 466 

Papilloma 466 

Papilloma Area Elevatum 467 

Papilloma Neuroticum 467 

Nsevus Pigmentosus 467 

Linear Nsevus 468 

Acanthosis Nigricans 469 

Xerosis 470 

Ichthyosis 471 

Congenita 474 

Linguae 474 

Onychauxis 477 

Paronychia , 478 

Onychomycosis 478 

Syphilitic Onychia 478 

Hypertrichosis ■ . 480 

Neurotica 481 

Plica Polonica 481 

Neuropathic Plica 482 

(Edema Neonatorum . ' , . . . 486 

Acute Sclerema Neonatorum 487 

Scleroderma 488 

Hemiatrophia Facialis . 491 

Elephantiasis 494 

Lymph-scrotum ' 496 

Acromegaly 497 

CLASS V. 

ATROPHIES. 

Leucoderma 501 

Alhinismus 502 

Vitiligo 502 

Canities 505 

Alopecia 507 

Congenitalis 507 



CONTENTS. xiii 

PAGE 

Alopecia Senilis 508 

Prematura 508 

Furfuracea 509 

Areata 511 

Circumscripta 513 

Follicularis 518 

Keloid-Acne 520 

Ulerythema Aphryogenes 521 

Atrophia Pilorum Propria 522 

Fragilitas Crinium 522 

Undescrihed Form of Atrophy of Hairs of Beard 522 

Trichorrhexis Nodosa 522 

Monilethrix 524 

Nodose Swellings of Shafts of Hair 525 

Expansions and Fissures of Hairs 525 

Lepothrix 525 

Piedra 526 

Beigel's Disease 526 

Tinea Nodosa . . . 526 

Atrophia Unguis 526 

Achromia Unguium 527 

Atrophia Cutis 528 

Senilis 528 

Maculosa et Striata 529 

Diffuse, Idiopathic 530 

Partial Symptomatic 530 

Glossy Skin 531 

Blanching Atrophy of Skin 531 

Multiple Benign Tumor-like New-growths 532 

Kraurosis Vulvae 532 

Perforating Ulcer of the Foot 533 

Morvan's Disease 534 

Ainhum 535 



CLASS VI. 

NEW-GKOWTHS. 

Keloid 539 

Cicatricial Keloid 540 

Cicatrix 542 

Fibroma 544 

Dermatolysis 546 

Neuroma 548 

Xanthoma 550 

Xanthoma Diabeticorum 554 

Colloid Metamorphosis of the Skin " 555 

Adenoma of the Sebaceous Glands 556 

Coil-glands ; 558 

Multiple Benign Cystic Epithelioma 558 

Lymphangioma Tuberosum Multiplex 559 

Leukeratosis Buccalis 560 

Myoma 562 

Angioma 563 



xiv CONTENTS. 

PAGE 

Angioma Nsevus Vasculosus .' 563 

Telangiectasis 564 

Cavernosum 565 

Serpiginosum 568 

Lymphangioma 569 

Circumscriptum . 570 

Xeroderma Pigmentosum 572 

Rhinoscleroma . , 574 

Tuberculosis Cutis 576 

1. Lupus Vulgaris 576 

2. Tuberculosis Cutis Verrucosa 581 

A. Verruca Necrogenica 581 

B. Tuberculosis Verrucosa Cutis 582 

C. Other Verrucous Tuberculoses 582 

3. Tuberculosis Cutis Orificialis 583 

4. Scrofuloderma 584 

Tuberculous Dactylitis 586 

Suppurative Tubercular Lymphangiectasis 586 

Tuberculosis Cutis Serpiginosa 586 

Lymphangitis Tuberculosa Cutanea 586 

5. The Dermatoses of the Scrofulous 599 

A. Lichen Scrofulosorum 599 

B. Erythema In dura turn Scrofulosorum 600 

C. Necrotic Granuloma . . 601 

D. Eolliclis 602 

E. Lupus Pernio 602 

Erysipelas Perstans 603 

E. Pustular Scrofuloderm 603 

Acneiform Group of Para-tuberculoses 603 

Lupus Erythematosus . . . 604 

Syphilis ' 614 

Chancre -. 616 

Syphilodermata 619 

Syphiloderma Maculosum 623 

Papulosum 626 

Vesiculosum 631 

Pustulosum 631 

Bullosum 634 

Tuberculosum 635 

Serpiginosum 635 

Gummatosum 637 

Erythanthema Syphiliticum 638 

Syphilis of Mucous Surfaces 639 

Syphiloderma Infantile, Acquisitum et Hsereditarium 641 

Chancroid 665 

Lepra 670 

Tuberosa 671 

Maculosa 673 

Angesthetica 674 

The Sartian Disease 683 

Frambesia 684 

Parangi 685 

Doncla Ndugu • 686 

Verruga Peruana 686 



CONTENTS. xv 

PAGE 

Mycosis Fungoides 687 

Sarcoma Cutis 693 

A. Melanotic Sarcoma 698 

B. Primary Non -melanotic Sarcoma 694 

Idiopathic Multiple Pigment Sarcoma 695 

Kecurrent Fibroid of the Skin 695 

Carcinoma 697 

Epithelioma 697 

Superficial, or Discoid 697 

Kodent Ulcer . . 697 

Deep 698 

Papillary 699 

Cancer of the Head 700 

Lower Lip , 701 

Genital Organs 701 

Extremities 702 

Mucous Surfaces 702 

Paget's Disease 708 

Cancer of Connective Tissue 709 

en Cuirasse 710 

Tuberose Carcinoma 711 

Melanotic Carcinoma 711 

Endothelioma 712 



CLASS VII. 

SENSOKY DEKMATO-NEUKOSES. 

Hyperesthesia 713 

Dermatalgia 714 

Anaesthesia 716 

Paresthesia 716 

Pruritus 717 

Hiemalis . . 718 

Prairie Itch 725 

Myxcedema 726 

CLASS VIII. 

PAEASITIC AFFECTIONS. 

Disorders due to Vegetable Parasites 729 

Tinea Favosa 729 

Favus of the Nail •. 731 

Tinea Trichophytina . . 737 

Tinea Circinata 739 

Eczema Marginatum 741 

Tinea Trichophytina Unguium 741 

Tinea Tonsurans 746 

Tinea Kerion 752 

Tinea Sycosis 753 

Precautions in Tinea Favosa and Trichophytina 758 

Tinea Imbricata 759 

Tinea Versicolor 760 



xvi CONTENTS. 

PAGE 

Erythrasma 764 

La Perleche 766 

Myringomycosis 766 

Carates 767 

Mycetoma 768 

Actinomycosis of the Skin 771 

Blastomycosis of the Skin 774 

Refractory Subcutaneous Abscesses caused by Sporothrix 778 

Diseases due to Animal Parasites 778 

Scabies 778 

Demodex Folliculorum - 788 

Pulex Penetrans 789 

Irritans 789 

Eilaria Medinensis 790 

Craw-Craw 792 

Cysticercus Cellulosae Cutis 792 

Echinococcus 793 

Distoma Hepaticum 793 

Leptus 793 

Dipterous Larvae in the Skin 795 

Ixodes 796 

Pediculosis 796 

Capillitii 797 

Corporis 799 

Pubis 802 

Vagabond's Disease 804 

Pediculi and Acari from Lower Animals 804 

Cimex Lectularius 805 

Culex Pipiens 806 

Protozoa and Sporozoa 807 






LIST OF ILLUSTRATIONS. 



FIG. PAGE 

1. Section of skin from the palm of the hand 18 

2. Subcutaneous fat-tissue 20 

3. Columnae adiposse 22 

4. Vertical section of skin after injection (from beneath) with Berlin blue 23 

5. Vascular and nervous papillae 24 

6. Scalp of a colored man — horizontal section 25 

7. Prickle-cells 26 

8. Pacinian body, after silver staining 31 

9. Section of papilla containing a tactile body (from the skin of a finger) 32 

10. Transverse section of nervous papilla 33 

11. Section of hair-follicle during the formation of a new hair 37 

12. Hair-follicle in longitudinal section 37 

13. Lower portion of hair-pouch from the lip of a kitten 39 

14. Transverse section of hair and follicle 40 

15. 16. Sebaceous glands of the second class from the alae of the nose . 42 

17. Coil of a sweat-gland 43 

18. A sweat-pore traversing the epithelial layers of the skin 44 

19. Section of skin from the palm of the hand 45 

20. Thin section of the skin of the finger removed at the site of a 

sweat-pore 47 

21. Vertical section of one-half of nail and matrix 48 

22. Implantation of the nail at its border 50 

23. Irido-platinum needle 107 

24. Milium needle 107 

25. Scarifying-spud 107 

26. Epilating-forceps 108 

27. Piffard's grappling-forceps 108 

28. Piffard's cutisector 108 

29. 30. Dermal curettes 108 

31. Hess's glass pleximeter 108 

32. Comedo-extractor 108 

33. Cutaneous punch 108 

34. Massering-ball 108 

35. Section of a comedo 138 

36. Cysts of the scalp 144 

37. Photomicrograph of the bacillus scarlatinas 155 

38. Vertical section of pustule at the beginning of pustulation in variola 159 

B xvii 



xvm LIST OF ILLUSTRATIONS. 

FIG. PAGE 

39. Vertical section of one-half of an undeveloped pustule 161 

40. Autographism in urticaria 189 

41. Urticaria pigmentosa 197 

42. Papilloma, due to ingestion of the iodine compounds 211 

43. Feigned eruption 217 

44. Vertical section of carbuncle 230 

45. Section of carbuncle 230 

46. Authrax bacilli and pus-corpuscles 234 

47. Longitudinal section of the third spinal ganglion of the right lumbar 

region, from a case of lumbo-inguinal zoster 263 

48. Vertical section of skin from a patch of psoriasis 276 

49. Acne necrotica 410 

50. Hydroa vacciniforme 425 

51. Molluscum epitheliale 453 

52. Molluscous corpuscles 454 

53. 54. Cutaneous horns 459 

55. Vertical section of the summit of a pointed wart 464 

56. Ichthyosis hystrix , 472 

57. Ichthyosis hystrix, vertical section 473 

58. The Russian " dog-faced man " 480 

59. Elephantiasis of the foot and leg 496 

60. Elephantiasis scroti 496 

61. Vitiligo in a negro boy 504 

62. Trichorrhexis nodosa 523 

63. Keloid 540 

64. Multiple fibromata 545 

65. Neuroma of the skin ; external appearance 548 

66. Microscopic structure of neuroma 549 

67. Lupus vulgaris of the leg 580 

68. Verruca necrogenica 581 

69. Section of lupus of the face 589 

70. Lupus erythematosus of the face 605 

71. Chancre of the tongue 617 

72. Facial cicatrices of tubercular syphilodermata after twenty-five years 

of infection 622 

73. Vegetating condylomata of the vulva 629 

74. Ulcerative tubercular syphiloderm 636 

75. Syphiloma of the vulva with gummatous changes in labia and clitoris 637 

76. Lee's safety-lamp for fumigation 658 

77. Lepra tuberculosa 671 

78. Tubercular leprosy 672 

79. Anaesthetic leprosy with mutilating results 675 

80. Larynx of patient affected with lepra tuberculosa 677 

81. 82. Larynges of lepers affected with lepra tuberculosa 678 

83. Bacilli of leprosy 679 



LIST OF ILLUSTRATIONS. xix 

FIG. PAGE 

84. Mycosis fungoides 689 

85. Sarcoma 696 

86. Epithelioma, vertical section 703 

87. Cancer en cuirasse 710 

88. Achorion Schonleinii 732 

89. Epidermis invaded by trichophyton 743 

90. Hair invaded by trichophyton 749 

91. Filaments and spores of trichophyton from the beard 755 

92. Microsporon furfur 762 

93. Microsporon minutissimum 765 

94. Osseous lesions in mycetoma 769 

95. Blastomycosis 775 

96. Female acarus 779 

97. Acarian furrow 781 

98. Demodex folliculorum 789 

99. Leptus Americanus 794 

100. Leptus autumnalis 794 

101. Rouget 794 

102. (Estrus 795 

103. Larvae from body of child 795 

104. Pediculus capillitii 797 

105. Ova of head-louse 797 

106. Pediculus corporis 799 

107. Pediculus pubis 803 



LIST OF PLATES. 



Plate I. Nsevus Lipomatodes frontispiece. 

Plate II. Erythema Multiforme, Circinate type facing page 180 

Plate III. Dermatitis Herpetiformis facing page 265 

Plate IV. Pityriasis Rosea facing page 289 

Plate V. Pityriasis Rubra Pilaris facing page 296 

Plate VI. Acne-keloid of the Back facing page 394 

Plate VII. Purpura due to Copaiba . facing page 42i» 

Plate VIII. Keratosis Punctata facing page 448 

Plate IX. Palmar Keratosis due to Arsenic facing page 449 

Plate X. Congenital Warts facing page 461 

Plate XI. Syphilis of the Nails facing page 478 

Plate XII. Circumscribed Scleroderma facing page 489 

Plate XIII. Elephantiasis Telangiectodes of the Upper Lip 

and Portions of the Face facing page 495 

Plate XIV. Malum Perforans Pedis, with Symmetrical 

Keratoma of the Palms and Soles . . . . faring page 533 

Plate XV. Multiple Fibroma of the Back facing page 544 

Plate XVI. Fibroma Pendulum facing page 546 

Plate XVII. Xanthoma of the Hands, Elbows, and Knees . facing page 550 

Plate XVIII. Xanthoma Tuberosum of Hands facing page 551 

Plate XIX. Xanthoma Diabeticorum facing page 554 

Plate XX. Lupus Hypertrophicus of the Face facing page 577 

Plate XXL Large Pustulo-crustaceous Syphiloderm of the 

Scalp and Body facing page 632 

Plate XXII. Tubercular Syphiloderm, Resolutive and Ser- 
piginous facing page 635 

Plate XXIII. Pre-fungoid Stage of Mycosis Fungoides . -.facing page 687 

Plate XXIV. Microsporon Audouini and Megalosporon 

Endothrix, X 500 facing page 737 

Plate XXV. Mycetoma facing page 768 

Plate XXVI. Blastomycosis of the Skin facing page 774 

Plate XXVII. Histological and Bacteriological Features of 

Blastomycosis facing page 111 

xx 



I. ANATOMY AND PHYSIOLOGY OF 

THE SKIN. 



The skin is the living envelope of the human body; it is closely 

associated with underlying structures;, and by its situation is brought 
into intimate relation also with the external world. The skin is a 
complex, elastic, and sensitive organ, varying greatly in different con- 
ditions of climate, age, sex, health, and race; and varying also in the 
characteristics exhibited in different localities upon the same indi- 
vidual. Thus, in color there is a wide range between the fair skin of 
the blonde and the black skin of the negro, between the rosy pink of 
the infant's palm and the dark-brown hue of the genital region of the 
aged. J ne skin varies also in pliability and thickness, being delicate 
and lax over the eyelids, the lips, and the prepuce?; and much thicker 
and more firmly attached over the palms and the soles. 

The appearance of the skin, even in conditions of health, changes 
within appreciable limits. It i- the exposed parts (such as the face) 
which the eve of the physician most frequently searches, and which 
betray evidence of mental emotions, physiological fluxes, sedentary or 
active habits of life, and fatigue or unusual conditions of vigor. 

Viewed externally, the -kin i-> -ecu to be traversed by superficial 
and deeper furrows, dotted with numerous depressions representing the 
mouths of its follicle-, at the digital extremities protected by the nails, 
and provided very generally with coarse or with fine, downy hairs, 
which in some parts are of sufficient growth to conceal the skin from 
view. This pilary growth serves not merely as an ornament of the 
body, but also as a protection to some of its regions most sensitive to 
thermal changes. 

By its extraordinary sensitiveness to different degrees of tempera- 
ture and to the physical properties of the bodies with which it is 
brought into contact the skin becomes, even when unaided by the eye, 
a valuable means of preserving the human frame from external in- 
jury. This protective function is, in part, due to the horny character 
of its outer layer, as a consequence of which the loss of essential fluids 
and the ingress of noxious substances are equally restricted. 

One of the most important functions of the skin is the part it 
plays in regulating the body-temperature. The temperature-variations 
at its surface, modified naturally by the character and quantity of the 
clothing when such is worn, produce corresponding variations in the 
smooth muscles and contractile blood-vessels of the skin. By enlarge- 
ment or diminution of the lumen of these vessels, whether resulting 
directly from the action of heat or of cold at the surra ce, or indirectly 
through an effect upon the vasomotor centres, large quantities of blood 
2 17 



18 



ANATOMY AND PHYSIOLOGY OF THE SKIN 



are brought to or removed from the superficies of the body. In oue 
case the blood is cooled by evaporation at the body-surface ; in the 
other, the loss of heat by such evaporation is greatly restricted. This 



Fig. 1. 



J_. 




m 



Section of skin from the palm of the hand, magnified l.")0 diameters: a, stratum corneum : 
a', its superficial layer ; b, stratum lucidum ; c, stratum granulosum : d. stratum mucosum(rete): 
e, pars papillaris of the corium, loops of capillary vessels showing in vascular papillae : f, pars 
reticularis of the corium, showing coarse interlacing connective-tissue bundles ; g. transverse 
section of the latter; h, double-contoured nerve-fibres passing to tactile body; i, coil-glands : 
k, ducts of coil-glands ; 1, sweat-pores passing to surface of the epidermis; m. arteries of the 
skin terminating in capillaries ; n, veins of the skin forming plexuses; o. fat-cells, encompas 
by capillary loops, in relation with coil-elands (the capillaries of the latter are purposely omitted 
in the drawing) ; p, obliquely and transversely divided bundles of connective-tissue fibres of the 
corium and subcutaneous tissue. 



ANATOMY. 19 

process is materially influenced by acceleration or retardation of the 
heart's action, whether produced by psychical or by physical causes. It 
is also modified by the occurrence of sweating, as a result of which heat 
in varying amounts is rendered latent, and either watery vapor escapes 
from the surface; or sweat is exuded in drops, the aggregate of which 
may be several pounds in weight in the course of twenty-four hours. 

To a limited degree the skin is capable of acting as a respiratory 
agent, eliminating carbonic acid gas with watery vapor, and possibly 
also absorbing oxygen in small amount. Its power of absorbing ali- 
ments, medicaments, and toxic substances has as yet but imperfectly 
been determined. Substances in a liquid state are practically not 
absorbed so long as the horny layer of the epidermis is intact. With 
this layer intact minute particles of matter have been conveyed to 
the deeper structures in the operations of skiagraphy, of cataphoresis, 
and of dielectrolysis. The actual loss, however, of this external 
protective layer permits the ready absorption of many liquids. Gases 
may be absorbed by the unbroken skin, and to a less extent are some 
fats and oils, as well as a few substances in a finely powdered state. 
Such absorption, when it occurs, is probably effected through the 
portal of a hair-follicle and the ducts of the cutaneous glands. 

The skin is provided with a natural unguent, by which, in a state 
of health, it is constantly anointed. The fatty and oily secretions of 
the skin are concerned n<>t merely in the anointing of the general sur- 
face and of the hairs, but also in the regulation of the body-tempera- 
ture and in the prevention of maceration of the tissues by the sweat. 

The complex organ called the skin is essential to the life of the 
individual. The sexual, and possibly other, organs of the human 
body may have their functions arrested, or they may even be obliter- 
ated by destructive processes, and life still continue; but if all the 
functions of the skin were suspended for a sufficient period of time 
the result would be fatal to human life. In its relations alone to 
the complicated processes by which the heat of the body is main- 
tained at a relatively fixed standard the skin exhibits its impor- 
tance to the general economy. It is thus seen to be, not an isolated 
membrane stretched mechanically over an artificial machine, but is one 
of several living and potential systems of the body, each system being 
in intimate union with all others. 

Developmknt of the Skix. — The corium is developed in intra- 
uterine life from the superficial layer of the mesoblast (the " skin-plate " 
of Remak). Its lower portions become first visible in a myxofibrous 
structure, which between the seventh and eighth months is replaced by 
a collagenous substance, from which the bundles of connective tissue 
develop, finer fibrillas becoming later elastic fibres. 

The epidermis springs from the ectoderm, and has therefore no 
primary histological relation with the corium, though at about the fourth 
month it is projected upon the papillary layer so as to give rise to the 
grooves and interdigitations which produce in the skin of the adult 
an important and intimate connection between the two. At first a 
single layer, later two, three, and more rows of prickle-cells develop 
up to the fifth month, the horny covering persisting up to the seventh 



20 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 



month merely as a thin stratum composed of but two rows of cells. 
The appendages of the skin are mostly developed between the sixth 
and eighth months. 

The integument of the body, when studied with the aid of the micro- 
scope, is found to be composed of several organic parts, which arc : the 
subcutaneous connective tissue (the hypoderm), resting on the deeper 
structures of the body ; then, more externally, the corium, or true 
skin ; lastly, an outermost coat, the epidermis, or cuticle Beside 
these parts, the skin contains coil-glands, sebaceous glands, hairs, nails, 
blood-vessels, lymph-vessels, muscles, pigment, and nerves. It will 
be instructive to study the deeper part- of* the -kin before considering 
those more superficially disposed, as their mutual relations will thus 
be made clearer. 



SUBCUTANEOUS TISSUE STRATUM SUBCUTANEUM . 

The subcutaneous tissue, or hypoderm, is differentiated from the 
corium between the third and the fourth month of foetal life. It 
is a structure serving a mechanical purpose as a receptacle lor fat, and 
for the support of vessels and nerves passing from the tissue beneath 
to the corium which lies next above 1 ii. It contains, also, coil-glands, 

some of the hair-follicles more 
Fig. 2. deeply seated than their fellows, 

and Pacinian corpuscles. There 
i> no distinct boundary-line be- 
tween the upper limits of the sul)- 
CUtaneous tissue and the overlying 
corium, to which it projects co- 
lumnar masses of fat, extending 
obliquely to the coil-glands and 
the hair-follicles above, often with 
lateral, horizontally disposed pro- 
longations of similar shape. It 
is built up of loose connective- 
tissue bundles, prolonged from 
the aponeuroses, fasciae, and the 
membranes lying beneath. 

The subcutaneous ti>sue is 
firmly attached to the skin over 
the extensor surfaces of the artic- 
ulations, the palms and soles, and 
the groins by short, coarse bundles, 
between which are single or mul- 
tilocular spaces lined with endo- 
thelia secreting a mucoid fluid. 
These spaces are the Bursae Mu- 
cosae. Elsewhere, as in the eye- 
lids, the penis, the scrotum, and the auricle of the ear, the attachment 
to the skin is by loose, delicate connective tissue containing no fat- 




Subcutaneous fat-tissue, the fat having 
been extracted with turpentine : B, bundles of 
fibrous connective tissue, carrying: injected 
blood-vessels ; C, capsules of fat-globules, 
with oblong nuclei. Magnified 500 diameters. 
(After Heitzmann.) 



t 



THE ('OIll CM. 21 

obules. All other fibrous tracts are arranged obliquely; they admit, 
\ their extension, of various degrees of pliability, and inclose rhom- 
boidal spaces containing more or less numerous fat-globules. These 
spaces are lobular d, are bounded by a delicate fibrous connective tissue, 
and are abundantly supplied with blood-vessels. This layer is termed 
the Panniculus Adiposus. 

The deposit of fat in the body i tly reduced in all disea 

productive of emaciation, bul never wholly disappears during life. In 
cases of obesity, fal is deposited in excess of normal limits, and it may 
then be concerned in the production or th< aggravation of disease. It 
is largely due to the greater or lesser volume of the panniculus adiposus 
that the natural outlines of the body are made to the eye graceful and 
attractive, or the reverse. 

Columnse Adiposae (Fat-columns of Warren). — These are 
columnar prolongations from the adipose tissue of the panniculus 
adiposus below, passing in nearly vertical position to the bases of the 
hair-pouches, especially conspicuous in the thickened integument of 
the hack, the neck, and the shoulders. The columnar axes are more or 
less parallel with the erectores pilorum muscles, and aid in supporting 
the coil-glands and the blood-vessels and lymphatic vessel.-. The 

rniirs jlhr< u.r of the Kn-lich ;nv e< »ne-~| iapcd DiaSSeS of connective tlSBUe 

which extend from the Lower borders "i the corium, and which pene- 
trate for a space into the adipose tissue. The part which these com- 
ponents of the skin play in the formation of carbuncle is set forth in 
that connection. 

THE CORIUM. 

The corium ( Derm \, ( "tit-. ( Jutis Veb \. or True Skin) i- com- 
posed of bundles of fibres of connective tissue, the decussations <>f which 
produce a dense felt-work, coarsesl toward the subcutaneous tissue 

, upon which it rests inferiorly, and finest in the outermost portion 
which is in contact with the epidermis above. The bundles are com- 
posed chiefly of fibres of white fibrous tissue, but are accompanied by 
a varying number of elastic fibres. Connective-tissue corpuscles are 
also present in small numbers. There is a u cement-substance," or 
basis-substance, surrounding all the fibre- and holding the various ele- 
ments of the skin together. The derma is rich in blood-vessels and 
capillaries, especially in the papillary layer, and contains many nerve-, 
nerve-endings, and terminal nerve-organs. It further contains lym- 
phatics, smaller muscle-fibres, hair-, sweat-glands, and sebaceous glands. 
Its thickness varies greatly with different individuals and at different 

< ages. It is thinnest in the infant, and on the eyelids, the prepuce, and 
the inner surfaces of the labia majora. It is thickest iti vigorous adults, 
and over the back, the buttocks, the palms, and the soles. 

The bundles of the connective tissue of the derma accompany all 
elongations of an epithelial character. They produce the follicles 

, around the root-sheaths of the hair, the capsules around the coil- 
elands, and the layers which surround their ducts. 

( Jorresponding with their anatomical structure the upper and lower 
portions of the derma are called respectively the "papillary layer" and 



22 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 



the " reticular layer." There is no sharp dividing-line between these 
layers, the pars reticularis passing gradually into the pars papillaris 
above and into the subcutaneous tissue below. 

Cleavage of the Skin. — The fibres and bundles of connective 
tissue in the skin are arranged according to a definite plan. Puncture 



Fig. 3. 




Vertical section of the skin showing : a, epidermis ; b, erector pili muscle; tf, columns adi- 
posse; c, coil-gland suspended in the columnse adiposse ; h, sebaceous gland; p, horizontal 
prolongations of the column ; /, fibrous bundles of the corium ; g, panniculus adiposus ; k, band 
of fibrous tissue extending into the panniculus adiposus. (After Wakken.) 

of the integument with a sharp and well-rounded instrument is pro- 
ductive not of a circular opening, but of a longitudinal slit. The 
extensibility and retractive power of the skin are largely dependent 
upon the arrangement of these fibres. 

Pars Eeticularis. — The reticular layer of the corium is made up, 
as has been seen, of interlacing connective-tissue bundles, with inter- 
spaces increasingly larger from without inward. The fineness of the 
bundles decreases, in the same way, from within outward, being finest 
where the minute papillae of the corium project into the rete, and 
coarsest near the subcutaneous tissue. 

Pars Papillaris. — The papillary layer of the corium lies in con- 
tact with the rete above, and is connected below with the deeper retic- 
ular portion of the true skin. Between the rete and the papillae of 
the derma a hyaline substance is interposed, which is supposed to be 
identical with the cement-substance surrounding and separating the 
fibrillar of the corium. The basal membrane once thought to be 
stretched between the rete mucosum of the epidermis and the papillary 
layer of the corium cannot be demonstrated to exist. 

Viewed obliquely with an amplification of about three hundred 
diameters, it will be seen that long and slender filaments from the 
prickle-cells of the mucous layer of the epidermis encircle in a spiral 



THE CORIUM. 



23 



direction both nervous and vascular papillae. At the apices of the 
latter these threads completely surround the connective-tissue fibres. 

The name of this portion of the derma is intended to describe its 
chief characteristics, the existence of numerous digital prolongations or 
nipple-like prominences of the corium, made up of delicate connective- 



Fio. 4. 




Vertical section of skin after Injection (from beneath) of areolar tissue with Berlin blue: 
((, epidermis ; /, corium ; g, panniculus adiposus ; h, sebaceous gland. (After Warhen.) 

tissue fibres which do not interlace and which are abundantly provided 
with nuclei. The papillae spring each from a single, or several from a 
common, ovoid base ; their bulbous, conical, or blunt apices reach into 
the rete, which also dips down between them in prolongations termed 
" rete-pegs." The papillae vary in size in different parts of the body, 
and also in their disposition and shape, being in places arranged in 
linear series, and in others in concentric whorls, with definite centres, 
thus producing crossing-furrows, visible to the naked eye as markings 
upon the outer surface of the epidermis. The largest are found on the 
palms and soles and over the inner faces of the digits. It has been 
estimated that one hundred are developed within each square millimetre 
of the body-surface. 

In horizontal sections of the skin the papillae, being transversely 
divided, appear as circular or ovoid areas, in which can be recognized 
centrally a transversely or obliquely divided capillary loop. Between 
these areas is seen the interpapillary reticulum of the mucous layer. 

The growth of the rete downward and of the corium upward results 
in mutual effects of pressure and counter-pressure the equilibrium of 
which is constantly adjusted by the mechanical and vital necessities 
of such union. 

When the papilla? are completely exposed, after removal of the 
overlying cement-substance and of the epidermis above, their exterior 
surface is seen to be uniformly marked with series after series of 



24 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 



alternating furrows and ridges of exceeding delicacy and more or less 
concentrically disposed. Into the grooves are admitted corresponding 
dentations that can be recognized on the under surface of the layer of 
epithelial cells next the corium. They may, however, be the furrows 
left after separation of the long prickles wrapped about the papillae 
and traceable to the mucous layer. 



Fig. 5. 




Vascular and nervous papillse : a, vessel ; 6, nervous papilla ; c, vessel ; d, nerve-fibre ; e, cor- 
pusculum tactus ; /, transversely divided nervous filaments ; g, epithelia of rete. (After Biesia- 
decki.) 

Two varieties of papillae are distinguished — the vascular and the 
nervous ; the former contain the terminal loops of a minute artery and 
vein, and the latter the terminations of medullated nerve-fibres. 

The greater number of the papillae are of the vascular variety, being 
traversed by a vertically disposed loop of vessels, consisting of an 
arterial and a venous capillary. The office of the vascular loop is 
evidently not merely to supply nutriment for the epidermis above, but 
also to provide for the cooling of the blood when brought in large 
quantities to the surface of the body. Occasionally, two or more of 
such loops can be recognized in a single papilla. 

The nervous papillae contain the tactile corpuscles, which subserve 
an important purpose in providing for the sensibility of the integument. 
The tactile corpuscles are described in connection with the nerves of 
the skin. Ultimate terminations of nerves can be recognized in the 
vascular papillae, and at times minute vascular loops can be seen in the 
papillae largely occupied with the corpuscles of touch. 



THE EPIDERMIS. 



THE EPIDERMIS (CUTICULA). 



25 



The epidermis (Scarf-skin, or Cuticle) is the most external of 
the several membranes of the body, being in close contact on one side 
with the corium, or true skin, and exposed on the other to the atmos- 
phere by which it is surrounded. The latter surface is therefore rela- 
tively drier, while the former is constantly moistened by fluids from the 
vessels which ramify beneath it. 

Fig. 6. 




Scalp of a negro— horizontal section: B, rete mucosum ; Pi, row of columnar epithelia 
(cut obliquely) supplied with dark-brown pigment-granules ; Pa, papilla (cut transversely) ; 
D, derma. Magnified 500 diameters. (After Heitzmann.) 

No genetic relation exists between the epidermis and the corium, not- 
withstanding their intimate union and mutual relationship. The epi- 
dermis is developed from the ectoderm, the corium from a superficial 
layer of the mesoblast. Their behavior both in health and in disease 
is marked by the widest difference. 

Herxheimer's Spiral Fibres begin with the line of union of the 
corium and epidermis, and run in a spiral or zigzag direction between 
the cells and parallel with their long axes. They are most abundant 
in the deeper portions of the rete, and lie for the most part parallel 
with the long axes of the palisade rete-cells. They have been supposed 
to be a part of the canal-system for the distribution of the juices sent 
to the rete. They are conspicuous in inflammatory states. Other views 
point to the protoplasmic character of the cell-spirals, as also to the 
possibility that they are related to the collagen of the corium. 

The epidermis varies greatly in thickness in different portions of 
the body ; for example, the epidermis of the palms and soles exceeds 
in vertical section that which covers the dorsum of the hands and feet, 
and that which protects such sensitive parts as the eyelids, lips, 
temples, and prepuce. The epidermis is composed of the following 
principal layers, named in order from within outward : the stratum 
mucosum, the stratum granulosum, the stratum lucidum, and the 
stratum corneum. Each of these strata, or layers, is histogenetically 



26 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 



derived from the one which is deeper in situation. Beside these, 
Ranvier and others recognize a stratum germinativum, a stratum 
filamentosum, a stratum intermedium, and a stratum disjunctum. 

The Rete Mucosum (Mucous Layee, Peickle-layee, Stratum 
Mucosum, Eete Malpighii or Malpighianum) is the deepest of 
the epidermal layers, and rests upon the corium below. It is now 
generally designated as " the rete." The corium is intimately united 
with it by a series of interdigitations, which are commonly described 



Fig. 7. 




Prickle-cells from a condyloma (magnified about 625 diameters) : a, cavity of cell-nucleus ; 
b, nucleus ; c, nucleolus; d, prickles— these are greatly developed on the protoplasm cf the 
cells. The dots on the surface of the protoplasmic mass represent the appearance of the prickles 
when directed toward the eye of the observer. Some of the protoplasmic threads are seen pass- 
ing from one cell to another. 



as prolongations of the derma into the substance of the rete, but it is 
equally true that the rete sends down prolongations (the " rete-pegs ") 
into the derma. The two, in the need of an intimate union to resist 
friction and to insure vascular supply, are thus closely locked together. 
The stratum mucosum is built up of nucleated epithelial cells, poly- 
hedral in outline and diffusely colored. These cells are masses of 
granular protoplasm, living matter, which by their relation to one 
another form a protoplasmic network enveloping the entire surface of 
the body and lining all channels and cavities in direct or indirect con- 
nection with the surface. These elements are flattened by reason of 
their apposition, and are separated from one another by an intercellular 
cement-substance. There is a system of channels between the epi- 
thelia by which the nutritive fluids are conveyed from cell to cell. 
All are, however, uninterruptedly united by delicate spokes, known as 
prickles, spines, or thorns. The living matter, which produces a deli- 
cate reticulum within each protoplasmic body, its points of intersection 
being termed nuclei, nucleoli, and granules, sends forth the filaments 
which produce continuity through all the living layers of the epithelial 
elements, as well as through the underlying layers of the connective 
tissue. The epithelia are unprovided with either blood-vessels or 



THE EPIDERMIS. 27 

lymph- vessels ; but are supplied with a large number of nerves, which, 
in the shape of very minute beaded fibres, traverse the intercellular 
substance, and which are in direct communication with the reticulum 
of living matter within the protoplasmic bodies themselves. 

The masses of protoplasm just described play the most important 
part in all the pathological and physiological processes observed in 
the skin. It is probable that in the embryo all the appendages of 
the skin are formed directly by their assimilative and reproductive 
processes ; and it is certain that in health and in disease they "ire the 
ultimate source of all secretions. 

Next the corium is a layer of cells, columnar in form, often largely 
provided with pigment, and arranged with their long axes nearly at 
right angles to the plane of that portion of the corium upon which they 
are superimposed. It is this row of cells which in certain cutaneous 
affections displays in largest measure the phenomena of karyokinesis. 
Segmentation of these cells occurs after a mitotic or thread-like meta- 
morphosis of the nucleus in the deeper layers of the rete (stratum ger- 
minativum). More externally the cells are rounded or cuboidal in 
shape, with large, distinct nuclei. They are not arranged in definite 
strata except in the outermost layers, where the cells are somewhat 
flattened and elongated (stratum filamentosum). Between the cells in 
the deeper layers outwandered leucocytes may at times be recognized. 

Langerhans' Cells are elongated, irregularly stellate, non-nucle- 
ated bodies found chiefly in the deeper parts of the rete. They have 
been looked upon as pigment-cells devoid of pigment, as wandering 
cells, lymphoid cells, and as colorless tissue-corpuscles. 

The Stratum Granulosum (Granular Layer) of the epidermis, 
lying immediately above the stratum filamentosum, is built up of three 
or four rows of horizontally disposed granular bodies, united to one 
another by short, broad threads. Between these bodies the intercellular 
spaces are so contracted that nutritive fluids cannot easily filter out- 
ward ; and the nuclei of the cells are usually shrunken. These have 
been studied carefully by Ranvier, Kolliker, Waldeyer, and others. 
According to these observers, the roundish granules which give this 
layer of epithelium its peculiar name and appearance consist of elei'din 
or keratohyalin, a substance essential to the process of cornification in 
the elements making up the horny layer of the skin, nails, etc. These 
granules first appear in the neighborhood of the nuclei of some of 
the large prickle-cells in the rete, but they are best studied in the 
granular layer, the cells of which are often completely filled with them. 
According to Unna, the color of the skin in the white races depends 
upon this layer alone. 

The Stratum Intermedium of Ranvier is practically a sub- 
division of the stratum lucidum, from which it is distinguished chiefly 
by the fact that it takes a reddish stain after treatment with picro- 
carmine. It is here that the process of keratinization of the epidermis 
is first to be detected. 

The Stratum Lucidum (Septum Lucidum) of Oehl lies imme- 
diately above the stratum intermedium, and appears under the micro- 
scope as a delicate, brightly colored line consisting of two or three rows 



28 ANATOMY AND PHYSIOLOGY OF THE SKIN 

of transversely disposed, glistening epithelia, differing in translucency 
from those situated on either side. The stratum lucidum thus marks 
with tolerable distinctness the boundary-lines of the rows of cells above 
and below it. Its epithelial bodies seem to have lost suddenly the 
refractive, shining granules of keratohyalin conspicuous in the 
stratum granulosum below. These granules are generally supposed to 
have disappeared in consequence of their solution in the protoplasm 
of the cell-body, which has thus acquired an added brilliancy and 
clearness. 

The Stratum Corneum (Horny Layer) of the epidermis is its 
outermost and widest layer, extending from the stratum lucidum below 
to the external environments of the body. In its lower portion the 
polygonal plates of which it is composed indicate very clearly their 
relationship to the cells in the prickle-layer. The nuclei appear in 
places only as shrivelled and inconspicuous relics of the protoplasmic 
threads ; or there may be merely vacant nuclear spaces marking their 
original site. Occasionally, on the edges, rudiments of the prickle- 
threads may still be recognized. More externally the dried, lifeless, 
horn-like plates of which this layer is composed become mere cornified 
shells, generally lying in horizontal strata, and becoming more curled 
and wrinkled as the surface of the skin is reached, often being imbri- 
cated, but preserving the polygonal outlines of epithelia relieved of the 
forces of pressure and counter-pressure exerted in the deeper parts of 
the epidermis. These elements are rarely pigmented, save in the case 
of the negro, in whom the intense staining of the deepest parts of the 
mucous layer extends measurably to the external strata. This staining 
in the colored races is produced by granules of pigment arranged about 
an unpigmented nucleus in the prickle-cells. The cells of the horny 
layer contain fatty material in very considerable proportion, a provision 
by which the suppleness of the skin is maintained and undue evapora- 
tion prevented. 

After digestion with pepsin and trypsin the horny cells may be seen 
to be connected by more or less persistent threads, visible after pro- 
longed digestion as a large-meshed reticulum, with strands formed from 
a double row of cornified filaments united by short horny bridges. 

The Stratum Disjunctum of Eanvier is the most superficial of 
the layers of the stratum corneum, differing chiefly from the latter in 
that it is indifferently colored by osmic acid. 

Epitrichiae Layer. — Welcker, 1 Minot, 2 and Bowen 3 have de- 
scribed a layer of large cells, with round nuclei much larger than those 
of the epidermal layers beneath, covering the entire body of the human 
embryo during the early months of its existence. This layer, histologic- 
ally, is quite distinct from the outer cells of the stratum corneum, and 
corresponds with the epitrichium of certain animals. It usually dis- 
appears before the sixth or seventh month of uterine life. 

1 Ueber die Entwickelung und den Bau der Haut und der Haare bei Bradypus. 
Halle, 1854. 

2 American Naturalist,, June, 1886. 

3 Anatomischen Anzieger, iv. Jahrgang (1889), Nr. 13 u. 14 ; and Jour. Cutan. and 
Ven. Dis., 1895, p. 485. 



BLOOD-VESSELS. 29 



BLOOD-VESSELS. 

The arteries and veins supply the skin from subcutaneous branches 
which penetrate the underlying fasciae, and proceed by subdivision to 
be distributed to all portions of the integument below the epidermis, 
the distribution being especially abundant about the glands and fol- 
licles of the skin and the inferior and superior parts of the corium. 
They are always more abundant upon the flexor than upon the extensor 
faces of the extremities. Just beneath the papillary laypr of the 
corium there is a minutely ramifying plexus of fine capillaries, the 
loops of which extend into the papillae above. This and the coarser 
plexus in the deeper portion of the derma are well defined, and have 
been designated as superior and inferior partes vasculares of the corium ; 
also, as the upper and lower vascular net. They are connected by more 
or less regularly placed and nearly vertical communicating branches. 
A fourth division of the vascular system of the skin is found in the 
subcutaneous connective tissue, in which the vessels are numerous ; a 
fifth is represented by the vessels distributed to the papillae; and lastly, 
a sixth includes the vascular channels supplying the accessories of the 
integument. 

The arterioles which supply the sweat-glands surround the coils 
of the latter in a delicate basket-like plexus, and terminate in two or 
three veinlets, one of which always accompanies the duct of the gland 
upward as far as the papillary layer, where it anastomoses with the 
vessels of that part of the skin. The ascending arterioles supply the 
sebaceous glands and hair-follicles, and, breaking up into smaller and 
yet smaller branches, finally furnish a single or a double capillary loop 
to each papilla. These capillaries of the papillary layer anastomose 
freely with those transversely arranged in the upper portion of the 
hair-follicles, from which loops also pass to the sebaceous glands. The 
hair-papilla has a vascular supply similar to that of each of the other 
papillae of the corium. 

Unna divides the vessels distributed to the skin into the papillary 
system and the system of the coil-glands and fat-tissue. The first 
system includes the ascending loops which traverse the vascular pa- 
pillae, and the branches supplying lower portions of the corium. The 
second system embraces the vessels running upward to the coil-glands 
and downward to the fat-tissue. In the papillary vascular system the 
arteries are narrow and the veins wide. Each of the vessels consists 
merely of an endothelial tube augmented, as the subcutaneous tissue is 
reached, by both media and adventitia. According to Hover, a sin- 
gular duplex arrangement of vessels in the distal phalanges of both 
fingers and toes results in a distinct communication between the arte- 
ries and veins. Other observers deny the existence of such anas- 
tomosis. 

Vasomotor nerves are twined around these vessels in all their rami- 
fications. The whole vascular system, as thus arranged, plays a most 
important part in all the healthy and morbid processes which occur in 
the skin, as well as in the physiological changes distinguishable to the 
eye in the phenomena of blanching and blushing. 



30 ANATOMY AND PHYSIOLOGY OF THE SKIN. 



LYMPHATIC VESSELS. 

The skin in all its parts is provided with a closed system of lym- 
phatic channels, designed to subserve the necessities of the important 
processes of absorption, and traversed by lymph the currents of which 
are continuously directed to the large vessels of the structures beneath 
the skin. These channels include: first, juice-spaces, provided or not 
with independent walls, usually without, and not freely communicating 
with the endothelium-lined vessels ; second^ lymphatic vessels proper. 
These conduits do not connect with blood-vessels. 

The juice-spaces, or lymph-spaces, separate the epithelial bodies which 
make up the stratum mucosum of the epidermis, and they also extend 
between the protoplasmic threads, or prickles, that unite them. Such 
conduits may be regarded either as delicate excavations in the cement- 
substance between the epithelia, or as irregular channels in a soft, 
viscid, albuminoid, and readily coagulable substance between the pro- 
toplasmic threads. At times this intercellular substance seems capable 
of obstructing the conduits by which it is tunnelled. These juice- 
spaces exist in the papillae of the corium, and encircle the several 
glands, hair-follicles, and nail-beds of the skin. They also sheathe 
the connective-tissue fibrillar of the corium and surround the fat-cells. 
According to Darier, the derma is a " true lymphatic sponge." 

The lymphatic vessels are relatively few, but they form a continuous 
meshwork with transversely and vertically disposed branches supply- 
ing all parts of the skin below the epidermis. The juice-spaces com- 
municate with these vessels in the papillary portion of the corium 
through minute orifices in the vascular walls, the vessels themselves 
being here represented by blind terminal loops. As these vessels pass 
to the deeper portions of the corium and below it they increase in size. 
The current of the lymph flows from the papillary apices to all parts 
of the rete, like the currents in the delta of a river, a reflux occurring 
at the lower limit of the interpapillary depressions of the rete down- 
ward, possibly through the sweat-pores which traverse the epidermis 
at these points. Thence the current flows freely downward to the 
lymphatic vessels in the corium, but the stream from the juice-spaces 
about the coil-glands and fat-tissue is retarded by reason of a more 
restricted communication with the lymphatic vessels below. In conse- 
quence of the retardation due to this anatomical peculiarity the forma- 
tion of fat by filtration is facilitated. 

NERVES. 

The skin, in view of the number and mode of distribution of its 
nervous elements, may be regarded as a vast area of sensitive nerve- 
terminals. INon-medullated and medullated nerve-fibres, each in places 
being substituted for the other, are supplied to the skin from horizon- 
tally disposed bundles of nerve-twigs in the subcutaneous tissue. These 
fibres traverse the corium in connection with the blood-vessels, and 
become finer as they ascend, until they form a subepithelial plexus just 
below the epidermis. 



NER VES. 



31 



Exceedingly delicate Non-medullated Fibres penetrate in great 
abundance to the epidermis between the epithelia, and are not to be 
confounded with the migratory cells found in this situation. Here, 
traversing the intercellular substance by the side of the juice-spaces, 
these fibres either terminate between the prickle-cells as ultimate bul- 
bous terminations of finely beaded fibrillar or penetrate the epithelia them- 
selves in pairs. Each prickle-cell is supplied with a pair of these beaded 
filaments, which may be either applied to the nucleus of the cell or be 
seen to encircle the nucleus more or less completely. Above the stra- 
tum granulosum these nervous threads cannot be recognized. 

Similar nerve-filaments are supplied to the sheaths of the hairs and 
the ducts of the coil-glands. It is by means of these numerous and 
delicate fibres that the perception of sensation in the skin is accom- 
plished. 

Motor filaments are also distributed to the sheaths of the blood- 
vessels (vasomotor nerves), in which they are finally lost. Other motor 
filaments supply the muscles, and trophic nerves are distributed to all 
the secreting organs of the skin and to all its protoplasmic formations. 

The Medullated Nerve -fibres of the skin in one or several loops 
pass upward into the papilla?, and then turn backward to the subpapil- 
lary region. Some of these fibres, after such reversion, again ascend to 
an adjacent papilla ; others are supplied to the Pacinian and tactile cor- 
puscles. 

Fig. 8. 





Pacinian body, after silver staining, 
showing superimposed endothelial lay- 
ers. (After Renaut.) 



Section of Pacinian body from a duck's bill; 
g.L, lamellar envelope; g.h, hyaline zone of the 
lamellar envelope ; b.t, terminal bulb of the nerve ; 
g.p, n.g.p, layer investing the cavity of the body. 
(After Renatjt.) 



The Pacinian Corpuscles (named from the anatomist Pacini), also 
called Corpuscles of Vateb, exist subcutaneously only upon nerves 
intended for cutaneous supply ; they are ovoid bodies, two or more mil- 
limetres in diameter. Each corpuscle consists of a series of concentric, 



32 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 



nucleated, vascular capsules, arranged after the manner of the capsules 
of the onion, more closely united at the periphery than at the centre, 
and surrounding a protoplasmic core. The medullated nerve to which 
the body is attached gradually loses its myeline envelope, and termi- 
nates in the centre of this core, after traversing the greater part of its 
axis, in one or several minutely club-shaped filaments. The myeline 

Fig. 9. 




Section of a papilla still covered by a portion of the stratum mucosum and containing a 
tactile body (from the skin of a finger). The corpuscle of Meissner is seen to consist of minute 
lobules, made up of a homogeneous protoplasm, with numerous oval nuclei and nervous fibrillse 
wound in a spiral direction about the mass of the corpuscle. The extension of the fibrillae to the 
mucous layer is shown. The sources of the nerve-filaments are demonstrated to be : (1) the axis- 
cylinders of one or two double-contoured nerve-fibres, splitting into their original fibrillse on 
arriving at the corpuscle, winding about the latter in characteristic spirals, and passing to the 
palisade-layer of the prickle-cells of the rete, between which, on account of the long prickles 
of the latter and the general resemblance of the two in thickness and contour, it is difficult to 
trace them further; (2) filaments from another double-contoured nerve-fibre (h) pass directly to 
the inferior layer of cells in the rete without establishing relations with the tactile body; (3) 
fibrillae derived from the network of nervous fibrillae in the pars papillaris of the corium (K), 
also passing more or less directly to the stratum mucosum. a, cells of the rete; 6, prickles of 
the latter; c, body of papilla ; d, nuclei of connective tissue forming papilla ; e, protoplasmic part 
of the tactile body with its nuclei ; /, fibrillae of the corpuscle ; g, double-contoured nerve-librcs 
directly supplying the rete ; k, nervous fibrillae derived from the network in the pars papillaris : 
I, nervous fibrillae entering the epidermis between the rete-cells, leaving the rorpusculum tactus 
at m. 



sheath is lost in the tissue of the concentric capsules. The nerve may, 
after supplying one capsule, penetrate a second or even a third. In 
such cases the nerve regains its sheath as it issues from the corpuscle at 
its opposite pole. Robinson believes that the nerve forms a plexus or 
loop within the corpuscle, and escapes from it at one of its poles. 

The precise function of the Pacinian corpuscle is unknown. Its 



NERVES. 






connection with the tactile sense is suggested by its location, since 
these bodies are most numerous in the subcutaneous tissue of the nipple, 
the penis, the digits, and in parts similarly sensitive. These corpuscles 
bear an analogy to the organ of vision : each body having a capsular 
character; each being provided with a special nerve-filament, which 
enters the corpuscle at one pole; each also receiving its impressions at 
the extremity of the capsule opposite that at which it receives its 
nervous supply. 

Fig. 10. 




Transverse Bectlon of nervous papilla surrounded by cells of the stratum mucosum: a, 

{trotoplasmic lobules of the corpusculum tactus; b, nervous fibrillar spirally wound about the 
atter; c, transverse section of double-contoured nerve-fibres ; </, cavity of nucleus (.out of focus). 



According to Krause, the Pacinian corpuscles aid in the appreciation 
of impressions produced by pressure and traction. Whether specially 
concerned in distinguishing sensations of heat, cold, moisture, pressure, 
traction, or weight, it is evident that they contribute but little, if at all, 
to the perception of ordinary impressions upon the skin, and they are 
not known to play any part in cutaneous diseases. 

The Tactile Corpuscles (Corpuscles of MEissNERoroF Wagner) 
arc ovoid bodies found in about one in four of the papilla? in the pars 
papillaris of the corium. Each corpuscle is composed of from one to 
three capsules. Minute lobules of a homogeneous protoplasm with 
oval nuclei are found in each. These corpuscles receive medullated 
nerve-fibres, and arc made up of closely compressed, flat connective- 
tissue fibres with minute nuclei, which are so packed together as to 
form a spindle-shaped mass occupying the greater part of the papilla 
in which each corpuscle is found and surrounded by a somewhat denser 
connective-tissue capsule. The myeline sheath of the nerve-fibres is 
lost in the fibrous tissue of the corpuscle. Externally viewed they 
seem to be transversely striated. 

The axis-cylinder of the nerve-filament distributed to each corpuscle 
divides into numerous delicate nerve-threads which in part encircle the 
3 



34 ANATOMY AND PHYSIOLOGY OF THE SKIN. 

corpuscles and also penetrate within. Each corpuscle is provided with 
an afferent and an efferent nerve, the former approaching the corpuscle 
from the subpapillary region and entering at or near its base. Occa- 
sionally the afferent fibre is furnished by an adjacent papilla. As the 
filament that enters the corpuscle frequently divides, two or more 
efferent fibres may then escape from it. Afferent fibres reach the rete 
above after encircling the tactile corpuscles ; others, side by side, arrive 
at the rete without coming into contact with the former. 

The discovery of nerve-filaments in and among the epithelia of the 
epidermis in such abundance as to provide fully for tactile sensation 
in the skin leaves the exact function of these corpuscles in partial ob- 
scurity. There can be little doubt, however, as to their association 
with the perception of certain qualities of foreign bodies with which 
the skin may be brought into contact. 

Merkel's Touch-cells are oval, nucleated bodies found in the 
lower animals, but also in man. They are supposed to be connected 
with the ultimate nerve-fibres. They resemble cells in a mitotic state, 
and are found in the upper part of the corium as well as the epidermis, 
and in regions in which the tactile corpuscles are few, as over the 
abdominal surface. 

The Corpuscles of Krause (Bulb-corpuscles: Kolbenkor- 
perchen) are rounded or oval-shaped bodies formed of a connective- 
tissue envelope and a non-nucleated bulb to which some delicate nerve- 
fibres penetrate. These bodies are found chiefly along the borders of 
the lips, over the glans penis, the clitoris, and the tongue. 

PIGMENT. 

The hue of the living integument is due in part to the degree of 
vascularity and distention of the vessels in the corium, and in part 
also to pigmentation of the epidermis. The coloring-matter of the 
skin in health is deposited chiefly in from one to four rows of cells 
in the lower stratum of the rete, the fine granules of pigment staining 
both the cell-bodv and the nucleus, the latter more vividly. The 
degree of vascularity of the skin is responsible for most of the flesh- 
tints, but the colors seen in the various races of men are wholly related 
to the character and quantity of pigment found in the rete. Rarely, 
pigment-cells are found in the corium in a state of health. This 
pigmentation depends upon a distinct and uniform coloration of the 
epithelia, and also upon minute granules of pigment entangled in the 
reticulum of living matter in the same part. Extreme variation in 
the distribution of pigment is noticeable both in health and in disease, 
and in individuals and races, being at times related to climatic and 
similar influences. This fact is well illustrated by the wide range 
between the flaxen-haired, pink-eyed albino and the blackest specimens 
of the negro, each, with small exception, being of African descent. 

It has already been noted that in the colored races the pigment may 
stain the epithelial cells and their nuclei as high as the granular layer ; 
and that to this layer only is due the characteristic color of the skin 
of the white races. Pigment is not normally found either in the horny 



MUSCLES. 35 

layer of the skin or in the subepithelial tissues. Waldeyer claims to 
have recognized it in normal connective tissue. 

The source of the pigment in the skin has not been positively de- 
termined. It is believed by some to be carried by leucocytes from the 
corium beneath to the rete above; others have thought that the pig- 
mented cells themselves were capable of migration. Yet others teach 
that the pigment is produced de novo within the rete-cells. It is most 
probable that the pigment is derived from the subepidermal structures, 
and is originally obtained from the blood itself. 

The relation existing between the two sources of skin-coloration, 
viz., the blood and pigment, is interesting and suggestive. The un- 
aided eye, looking at the outer surface of the body, makes little dis- 
tinction between these two color-sources. It is certain that solar heat 
exerts a manifest influence upon both, and that in extravasations of 
blood into the substance of the skin every shade of color visible in the 
spectrum may at times be distinguished. 

MUSCLES. 

Striated Muscular Fibres extend from the subcutaneous tissue into 
the derma; in the case of man they are found chiefly upon the face 
and neck, where they are the analogues of more powerful skin-moving 
muscles possessed by several of the lower animals. Some, as those in 
the region of the lace, serve to give expression to mental emotion by 
the production of facial movements. 

Non-striated Muscular Fibres exist either as minute oblique fas- 
ciculi in connection with the glands and follicles of the skin; or as 
annular bands, such as those which surround the nipple; or as radiat- 
ing and more or less parallel rods, such as antagonize the orbicularis 
in the eyelids. 

The Arrectores (Erectores) Pilorum are muscles found usually 
in connection with the hair-follicles. They originate by minute multiple 
fasciculi from the papillary portion of the corium, and are inserted at 
several points into the outer layer of several adjacent hair-follicles, just 
above the plane <>t' the apex of the hair-papilla. Their general direc- 

1 tion is oblique, and their muscle-bundles are embraced and traversed 
by elastic fibres which form a dense network about them. Elastic 
threads also connect them intimately with the connective-tissue bun- 

( dies of the corium, and serve as tendons at either extremity of each 

i muscular fasciculus. 

The muscles, by virtue of their oblique direction and mode of attach- 
ment, include in the angle subtended by their muscular fibres the 

I sebaceous glands connected with the hair-follicles. It follows, there- 
fore, that by their contraction they aid in the expulsion of the seba- 
ceous secretion formed in the gland ; but their intimate union with 
the elastic tissue, which is evenly and generally distributed throughout 
the framework of the corium, results in their discharge of a still more 

I important function in connection with the regulation of the body-tem- 

' perature, since by virtue of direct compression exerted upon the skin 
the blood may be driven from the surface in a centripetal direction 



36 ANATOMY AND PHYSIOLOGY OF THE SKIN. 

and its cooling in a great degree prevented, as in the well-known 
phenomena resulting in the production of the cutis anserina, or " goose- 
flesh." The reverse of this naturally follows when the muscles expand 
under the influence of external heat. The anatomical connections of 
the arrectores pilorum are such that their contraction serves to ap- 
proximate several of the papillae of the corium, including the hair- 
papilla. Thus, by their contraction the sebaceous secretion may be 
extruded, or, as is more particularly exhibited in the lower animals, 
such hairs as the bristles of the boar may be erected. 

Muscular Membranes exist in the skin of the scrotum, over the 
penis, about the nipple, and elsewhere. They are simply layers of 
smooth muscular fibres, which suffice when contracting to move the 
portions of skin to which they are distributed. 

HAIES. 

Hairs are cylindrical, elongated, and pointed epithelial filaments, 
derived from the epidermis, and obliquely implanted in depressions in 
the rete and corium, known as " hair-sacs," or " hair-follicles." They 
are found on all the superficies of the body except the palms and 
soles, the dorsum of the distal phalanges of the hands and feet, and 
the skin of the penis. Hairs occur in three tolerably distinct classes. 
These are : the fine, downy hairs, or lanugo, covering the face, the 
trunk, and the limbs ; the long, soft hairs, such as those implanted 
upon the scalp, the pubes, and the axillae ; and the short hairs, includ- 
ing the soft varieties seen upon the brow and the stiff hairs of the 
eyelids. 

The hairs are first developed in the third month of foetal life, when 
a short epithelial, cone is formed, the base of which is gradually sur- 
rounded by connective-tissue cells, and finally indented from below by a 
rudimentary hair-papilla. Gradually the tip of the rudimentary hair 
perforates the primitive hair-cone and becomes a mature filament. 
At about the period of birth, sometimes earlier, occasionally later, 
the " bed-hairs," as they are called by Unna, are replaced by papil- 
lary hairs. The term bed-hair is applied to primary hairs unprovided 
with papillae, and implanted in shallow follicles, from the sides of 
which productive epithelial offshoots have been sent out. Usually at 
the end of foetal life these bed-hairs have been for two months growing 
out of the hair-bed, or that part of the epithelium found in the cen- 
tral part of the hair-sac. 

Hairs thus differ from nails not only in their anatomical features, but 
particularly as to their physiological reproduction. Hairs are period- 
ically cast off and replaced by new filaments. The nails are shed and 
reformed only in disease ; in health they enjoy a continuous growth 
during the life of the body. When a hair is about to be shed it sepa- 
rates from its papilla in the hair-follicle and rises in the latter till it 
reaches above the level of the papillary apex. It is for a time held 
in place with sufficient firmness by the prickle-layer only, thus forming 
the bed-hair already described. Later an epithelial bud is projected 
either into the vacant follicle below or into the corium on either side, 



HAIRS. 



37 



from which a new hair is formed, somewhat as the hair is formed in 
the primitive cone of foetal life. The subsequent growth outward of 
the new papillary hair separates the bed-hair from its connection with 
the prickle-layer, and this filament is shed. 



Fig. 11. 



Fig. 12. 




Section of a hair-follicle during the forma- 
tion of a new hair : a, external and middle 
root-sheaths ; b.vitreous membrane : c, papilla 
with vascular loop ; d, external root-sheath : 
i, internal root-sheath ; /, cuticle of hair-fol- 
licle ; g, cuticle of hair ; h, i, young hair ; I, 
bulb of old hair; k, debris of external root- 
sheath of hair recently expelled. (After 
Ebner.) 




Hair- follicle in longitudinal section: a, 
mouth of follicle ; b. neck ; c, bulb ; d, e, der- 
mic coat ; /, outer root-sheath ; g, inner root- 
sheath ; h, hair; k, its medulla; I, hair-knob ; 
m, adipose tissue ; n, hair-mnscle ; o, papilla 
of skin ; p, papilla of hair ; s, rete mucosum, 
continuous with outer root-sheath ; ep, horny 
layer ; t, sebaceous gland. 



In studying the mature hairs the parts to be considered are the 
hair-follicle, and the bulb, shaft, and point of the hair. 

Hair-follicle. — The hair-follicle is a sac-like pouch in the corium, 



38 ANATOMY AND PHYSIOLOGY OF THE SKIN 

in which depression the hair-filament is implanted by its bulb and there 
firmly secured. The direction of this follicle is always at an oblique 
angle with the plane of the cutaneous surface upon which it opens, and 
thus is determined the set of the hairs, which is always fixed and at a 
similar angle. Viewed as a whole, the integument of the body over its 
entire area exhibits determinate whorls of both short and long hairs 
with definite centres, such as those which may be recognized at the 
vertex of the scalp, the centres of the lips, the umbilicus, etc. By this 
disposition the symmetrical appearance of the hairy parts is preserved, 
and, as a consequence of the same provision, physiological loss of the 
hair of the head is not productive of deformity, but rather adds dignity 
to the aspect of the elderly man. 

The hair-follicle embraces the lower two-thirds of that portion of 
the hair which is imbedded in the skin, together w T ith the envelopes of 
the latter, termed the hair-sheaths. Above the sebaceous glands the 
sheaths of the hair-follicle are lost in the papillary layer. The follicle 
is constituted of the connective tissue of the corium in three layers : an 
external longitudinal fibrous layer ; a middle transverse layer ; and 
an internal homogeneous or vitreous layer. At the base of the sac a 
fibrous pedicle may often be traced as low as the subcutaneous tissue. 

If the hair-pouch were made artificially by thrusting into the skin 
from without inward a blunt-pointed pin before which the tissue was 
gradually pushed, it is evident that the external layer, the stratum 
corneum, of the epidermis would be the first depressed, and finally 
would form the inner surface of the pouch. This represents the inner 
root-sheath of the hair. Next to this the pin would carry before it the 
mucous layer of the epidermis, which then would form the outer root- 
sheath of the hair. Outside of both would lie the connective tissue of 
the corium. 

The Outer Root-sheath, or the prickle-layer of the hair-follicle, 
accompanies the involutions of the stratum corneum and the stratum 
granulosum from without into the funnel-shaped neck of the hair-pouch 
as far as the openings of the ducts of the sebaceous glands. There, 
abandoned by the two other layers of the epidermis, the root-sheath is 
thinned in proportion as the papilla, which rises from below and which 
it closely surrounds, increases in size. It thus forms a hollow cylinder 
traversed by the hair and its envelopes, with a relatively wide, external, 
funnel-shaped opening, only partially filled by the shaft of the hair, 
and a narrower opening within, which embraces the neck of the hair- 
papilla. 

The Inner Root-sheath, or " matrix " of the root-sheath, is exter- 
nally in relation with the outer root-sheath, or prickle-layer, of the hair- 
follicle. The protoplasm of the cells of which it is constituted contains 
keratohyalin in varying quantities, the amount being natural lv greater 
in the cells lying nearest the hair-filament. That part of the sheath 
formerly termed "Henle's layer" is the more externally situated cel- 
lular envelope of this internal root-sheath, and is most conspicuous in 
that part of the hair-sac above the level of the papilla. That part of 
the sheath formerly called " Huxley's layer " is the more internally sit- 
uated part of the same sheath, somewhat higher in the follicle. These 



HAIRS. 



39 



are not distinctly different structures, but only a single structure in 
different situations. Whether termed the internal root-sheath or the 
matrix of the root-sheath, it springs from the neck of the papilla, and 
rises as high as the neck of the follicle. It contains keratohyalin, which 
is actively concerned in the cornification of the hair-tissue. 

Between this internal root-sheath and the cells constituting the cor- 
tex of the hair there is found, according to Unna, the common matrix 

Fig. 13. 




Lower portion of hair-pouch from the lip of a kitten: F, follicle; T, transverse section of 
connective-tissue bundles of derma ; M, arrector pili muscle ; IS, inner root-sheath : OS, outer 
root-sheath; P, papilla ; C, cuticle; R, root of hair; H, hyaline, or so-called "structureless," 
membrane. Magnified 500 diameters. (After Heitzmann.) 

of the cuticulse, forming respectively the cuticle of the root-sheath and 
the cuticle of the hair. The former is composed of cells with their 
long axes parallel with the circumference of the hair, while those 
forming the cuticle of the hair are arranged perpendicularly to the sur- 
face. These cuticulse are securely locked together by projection of 
their cell-edges, while united in the hair-follicle. 

The Bulb (or Root) is that portion of the hair imbedded in the 



40 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 



Fig. 14. 



skin, toward which the shaft of the hair gradually increases in thick- 
ness as it descends. The bulb is embraced by the hair-follicle, though 
its root-sheaths are interposed and implanted below at the base of the 
sac upon a nipple-shaped prolongation of the corium that may be re- 
garded as analogous to the vascular papillae of the papillary layer of 
the corium. 

The bulb of the hair embraces the papilla, and is constituted of pig- 
mented cells externally, forming what is called the " cortex " or cor- 
tical portion. This is the larger of the two structures of which the 
hair is composed, and its cells become vertically elongated and narrow 
as they are pushed outward in the process of growth. 

The Shaft of the Hair is that portion which extends from the exit 
of the hair at the surface of the skin to its extremity ; the latter, when 
uncut, always tapers to a perfectly acuminate point, as illustrated by 

the uncut hairs of the eyelids and those of 
the lower animals. The hair-shaft is either 
straight, curled, wavy, or alternately varied 
in diameter. A transverse section pre- 
senting an ovoid or ellipsoidal outline sug- 
gests an irregularly compressed circle. The 
degree of this flattening varies in different 
races, and is the cause of variability with 
respect to straightness or curliness. As 
hairs are to a marked degree hygroscopic, 
and not only absorb but can be deprived 
of a portion of their water, these states of 
waviness are subject to variation according 
to the aqueous condition of the media by 
which an individual is surrounded. 

The color of the hair is dependent upon 
the pigment it contains, the color of the 
hair-cells, and the quantity of air contained 
in the medulla. Variation in these three factors produces the wide 
range between a snowy whiteness and an ebony black. 

The coloring-matter of the hair is thus stored in both its horny and 
its medullary portions, and is distinct both within and between the 
epithelial elements of which the hair is composed. This pigmentation 
corresponds in great part with the amount of pigment distributed to 
other parts of the integument, and sustains a close relation to the 
general nutrition of the body. Its subjection to the influence of the 
trophic nerves is well demonstrated by the phenomena of rapid blanch- 
ing of the hairs. Excessive sweating, whether physiological or induced 
by the action of pilocarpine, has also a distinct influence upon the shade 
of color of hair. 

The membrane which invests the shaft of the hair is the cuticle, 
composed of numerous flattened plates, non-nucleated and non-pig- 
mented, regularly overlaid so as to resemble closely adherent fish-scales 
when viewed under the microscope on the flat side, and the overlapping 
tiles of the roof of a house when seen on the edge. 

The Cortex of the hair, constituting the greater part of its bulk, is 




Transverse section of hair and 
follicle. 



SEBACEOUS GLANDS. 41 

composed of flat, nucleated, pigmented, fusiform epidermal cells. The 
strength, elasticity, and extensibility of the hair are chiefly due to the 
cortical substance, and in particular to the firmness with which these 
epidermal cells are attached to one another. 

The Medulla of the hair is found best developed in the short, strong 
hairs of the beard and eyelashes, being wanting in the lanugo-hairs. 
It consists of a loosely packed mass of epidermal elements with inter- 
spersed air-spaces, differing in shape, developed in the centre of the 
axis of the shaft. This part of the hair contains also the pigment and 
fatty matters, which are here arranged as in the rete of the epidermis. 
Seen under the microscope, the medulla appears as a continuous or 
interrupted longitudinal band extending from the bulb, or the part 
implanted in the follicle, to the extremity, or point, of the hair. The 
purpose of this difference in the constitution of the cortex and medulla 
of the hair is doubtless to insure, on well-known mechanical principles, 
a maximum of strength, extensibility, and elasticity, with a minimum 
of volume. 

SEBACEOUS GLANDS. 

The sebaceous, or sebiparous, glands are pyriform bodies, usually 
racemose in development, situated in the corium, never in the subcuta- 
neous tissue ; they furnish a more or less consistent and fatty secretion 
destined to anoint the skin and hairs. Thev can usually be distin- 
guished as of three classes, though only two of these classes include 
glands which are associated with hairs in the embryo. 

The first class includes the sebaceous glands, which, strictly speak- 
ing, are appendages of the hairs and hair-follicles. They are developed 
early in fcetal life from minute, lateral, bud-like prolongations from 
the outer root-sheath of the hair. From two to six of these prolonga- 
tions spring from the prickle-layer of the hair-follicle, and the prickle- 
cells in the axis of each bud speedily undergo fatty metamorphosis. 
In the mature gland each acinus is formed of a membrana propria 
supporting layers of nucleated cuboidal epithelia undergoing fatty 
metamorphosis. Gradually the fatty cells are pushed outward toward 
the duct of the gland, where, sooner or later, their rupture releases 
numerous drops of fat (sebum) just where the hair emerges from the 
closely applied follicle below to the funnel-shaped mouth of the hair- 
pouch above. Externally each gland is provided with a layer of con- 
nective tissue. Sebaceous follicles are found in connection with the 

1 long, soft hairs, as those of the scalp and the axillae, several being 
grouped around a single hair-sac. 

The second class includes the large and complex glandular structures 

! to which the lanugo-, or rudimentary, hairs seem accessory, the orifices 

\ of their respective ducts opening directly upon the cutaneous surface. 

| These glands are chiefly found upon the glabrous portions of the skin, 

i as upon the face in both sexes and upon portions of the trunk and 

' extremities. 

The third class includes those sebaceous glands, much the smallest 

f in number, opening directly upon the surface and unconnected with 
hairs or hair-follicles. Such are the glandular odoriferse of the male 



42 



ANATOMY AND PHYSIOLOGY OF THE SKIN 



and female genitalia, and those existing about the lips and in the areola 
of the nipple. These glands might be designated as " glands of the 
mucous orifices." 

The Meibomian and Tysonian Glands are of the largest order 
of sebaceous glands. The former exist within the free border of the eye- 
lids ; the latter, upon the glans penis and the inner face of the prepuce. 
They are unconnected with hairs, and in this respect differ from other 
types of sebaceous glands. 

Fig. 15. 




Sebaceous glands of the second class, from the alae of the nose. (After Sappey.) 



The Glandule Ceruminos^: are situated in the sebaceous tissue 
of the meatus of the ear, and contribute to the waxy secretions there 
furnished. The "glands of Moll" found in the eyelids are to be 
classed with the sweat-glands. 

The Sebaceous Secretion contains, chemically, water, palmitic and 
oleic acids, palmitin and olein soaps, and the saline constituents of the 
other organic animal compounds, chlorides and phosphates of the alka- 
lies and earths. The extrusion of the secreted sebum from the ducts 
of these glands is greatly favored by the action of the arrectores pilo- 
rum muscles, by the contractions of which the gland is to a degree com- 
pressed. This is the reverse of what occurs in the coil-glands, the 
secretion of which is impeded by the action of these same muscles. 



COIL-GLANDS. 



43 



COIL-GLANDS. 

The coil-glands (Sweat or Sudoriparous Glands, Glandule 
Glomtformes), found within the skin of all regions of the body, are 
globular coils situated in the subcutaneous tissue and in the deeper 
portions of the corium. They appear first in the fifth month of foetal 
life as buds projected down- 
ward from the prickle- Fig. 17. 
layer of the epidermis. 
These projections always 
form between the papillse 
of the corium, and spring 
from the rete-pegs between 
these papillae. Long, thin 
cones of epithelium thus 
gradually traverse the co- 
rium, and become slightly 
bulbous at the lower ex- 
tremity to form later the 
coil. The lumen, when 
formed, extends rapidly to 
the epidermis, and after 
this is reached there is 
formed from within out- 
ward an opening, which 
becomes the sweat-pore. 

After birth these glands 
are found in all parts of 
the body, but in certain 
regions, such as the axillae, 
the groins, the palms, the soles, and about the anus, the coil-glands are 
multiple, of unusual size, and often peculiarly arranged. They are 
specially numerous in the palms and soles, where, according to Krause, 
there are between two and three thousand to the square inch. 

The Coil is a convoluted tube, of fairly uniform lumen, terminating 
in a csecal pouch, lined with nucleated cubical epithelia in a single 
1 layer of granular appearance, which are the secretory cells of the gland. 
Outside of the tube are smooth muscular fibres running parallel with 
I or in a spiral direction about the coil. Surrounding both muscle- 
bundles and epithelium is a connective-tissue membrane. The glomer- 
ulus, or coil, is globular in outline and reddish yellow in color. In 
J the larger glands irregular dilatations and constrictions of the tube are 
conspicuous. 

The Excretory Duct of the coil-gland passes from the glomerulus 
| below to the epidermis above in a straight or a spiral course. It is 
I lined with a delicate hyaline cuticle (discovered by Heynold), beneath 
which is a double layer of cuboidal epithelium. Externally is a mem- 
I brana propria, unprovided with muscular fibres. Its outermost sheath 
' is the usual connective-tissue layer. When the duct reaches the border- 
line of the epidermis its inner cuticle and external connective-tissue 




Coil of a sweat-gland : S, tubule lined with cuboidal 
epithelia; T, central calibre of the tubule ; D, beginning 
of the duct; C, connective tissue with injected blood- 
vessels. Magnified 500 diameters. (After Heitzmann.) 



44 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 



sheath both are lost ; here it becomes a sweat-pore. It opens at times 
within a hair-pouch. 

The Sweat-pore is a continuation of the excretory duct of the 
coil-gland after the loss of its cuticle and connective-tissue sheath. It 
is the loss of these sheaths and the consequent intimate relation of the 
canal to the epithelia of the epidermis that furnish the special basis 
for this distinction. The sweat-pore is merely a wall-less canal or chan- 
nel, spirally directed or running a straight course from the duct of the 
coil-gland below to the outermost stratum of the epidermis above. It 




Sweat-pore traversing the epithelial layers of the skin: BP, papilla with injected blood- 
vessels; V, valley between two papillae; D, duct in the rete mucosum ; E, E, epidermal layer; 
PL, coarsely granular epithelia, deeply stained with carmine ; P, duct with corkscrew-windings 
in the epidermal layer. Magnified 200 diameters. (After Heitzmann.) 

has no other wall than that formed by the cells of the prickle-layer 
below and of the other layers of the epidermis, which successively sur- 
round this canal, narrow below and funnel-shaped above. Eleidin- 
granules are found in the cells which border the sweat-pore at a some- 
what lower plane than the stratum granulosum. Hence the lumen of 
the sweat-pore, if such a term be permissible, is in free communication 
with the juice-spaces of the epidermis. 

The Secretion of the coil-glands consists largely of globules of fat 
and granules of pigment. The function of the coil-glands, therefore, 
is plainly the lubrication of the skin with unguent, a task performed 
only in small part by the sebaceous glands, and by them chiefly for the 
pilary covering of the body. The palms of the hands and the soles of 
the feet are thus lubricated with fat by the coil-glands. 

The total number of coil-glands in the body is estimated to be 
between two and three millions, and the total length of the uncoiled 
glands about eight miles. These figures serve to give an approximate 
idea of their great physiological importance, and of the extent to which 
violation of the rules of hygiene possesses interest from a pathological 
point of view. 



COIL-GLANDS. 



45 



The function of the sweat-pores which communicate directly with 
the excretory ducts of the coil-glands is distinct from that of the coil- 



Fig. 19. 






;-a 



■* r 









3tf 










Section of the skin from the palm of the hand (hardened in Moeller's fluid and treated with 
glacial acetic acid), magnified 300 diameters, showing epidermis and pars papillaris of the corium 
traversed by the excretory duct of a coil-gland terminating in a sweat-pore : a, stratum corneum ; 
a', its superficial layer, the cells in the upper and lower layers somewhat larger than those 
situated between the two ; b, stratum lucidum ; c, stratum granulosum ; d, stratum mucosum ; 
e, rete-pegs ; /, interpapillary process of rete meeting duct of coil-gland : g, g, papillae em- 
braced by long prickles extending from lower palisade-layer of the rete ; h, blood-vessels of 
papillae; i, bundles of connective-tissue fibres of pars papillaris; k, section of spiral duct of 
coil-gland and sweat-pore. 

i 

' glands, since it provides for the transmission outward of the watery 
fluids of the skin. The channel described as the sweat-pore is in ample 



46 ANATOMY AND PHYSIOLOGY OF THE SKIN 

and free communication with the intercellular spaces of the epidermis ; 
and this anatomical peculiarity provides fully for the needs of evapo- 
ration at the surface of the body. 

The Sweat excreted by the body differs under varying conditions of 
temperature, humidity of the air, and the amount and character of the 
articles ingested by the individual, either as food, drink, or medica- 
ment. Nearly 98 per cent, of the secretion is pure water, the remain- 
ing proportions representing the saline constituents of the other fluids 
furnished by the animal in life. In all chemical analyses of the sweat 
a source of error lies in the difficulty of securing the. fluid secretion 
unmingled with that produced by the sebaceous glands ; and the same, 
it may be said in passing, is true of the chemical analysis of the sebum. 
According to Duhring, potassium iodide, benzoin, and succinic and 
tartaric acids may be excreted with the perspiration. 

Unna, following in the lines indicated by Meissner, asserts that the 
coil-glands actually produce the subcutaneous fat-cushion ; and the 
anatomical basis of such a statement is clear. The coil-glands and 
the fat-cushion appear at the same period of foetal life and develop in 
the same proportions. At birth the clusters of fat are most conspicu- 
ous where the coil-glands are most numerous. In the adult the greater 
number of coil-glands are subcutaneous in situation and are closely 
surrounded by fat-globules ; while those glands which do not descend 
below the corium, though not thus surrounded, are regularly met by 
columns of fat advancing toward them from below. The credit of 
discovering and naming these Fat-columns belongs to Warren, 
whose studies were principally directed to the anatomy of the thick 
cutis vera. 1 The back and shoulders of a vigorous adult furnish 
an integument much thicker than the hide of many pachydermatous 
animals. The papillae are imperfectly formed and are represented by 
an undulating line. The follicles of the lanugo-hairs penetrate only 
the superficial layers of the cutis. From the bases of the hair-folli- 
cles nearly vertical clefts, or slender, columnar-shaped spaces, extend 
obliquely to the panniculus adiposus. These shafts are named " fat- 
columns " or " fat-canals," as they are entirely occupied by adipose 
tissue. (See Figs. 3 and 4.) 

The fat-columns are four millimetres in length, and are slisrhtlv wider 
than the hair-follicles above. Their long axes form a slight angle with 
that of the follicle, but they are nearly parallel with that of the erector 
pili muscle. The horizontal prolongations are given off on either side 
of the middle of this axis, partly fat-filled. Near this point the coil 
of a sweat-gland is seen to be held in place by a few delicate fibres. 
The duct of the gland runs to the top of this space, whence it may 
be traced to the side of the hair-follicle. The connective-tissue fibres 
seem to terminate abruptly at the edges of these columns. The cleft 
slightly widens below, and on the side toward which its axis leans the 
fibers of connective tissue form a bundle penetrating below to the 
subcutaneous fat. The erector pili muscle is inserted partly into the 
base of the follicle and partly into the apex of the fat-canal. These 
columns correspond in number with that of the hairs. The blood- 

1 Satterthwaite's Manual of Histology, p. 420. New York, 1881. 



COIL-GLANDS. 



47 



vessels they contain, which spring from the subcutaneous plexus, bifur- 
cate at the lateral clefts. Unna demonstrates that the fat-columns 
invariably advance toward the coil-glands either singly or in groups, 
and that the connection of the fat-columns with the hair-follicles is a 
mere incident of that advance. 

The alternation of muscular fibres with the secretory cells of the 
ducts of the coil-glands is a provision for the extrusion of the gland- 
secretion onward. The same anatomical arrangement permits free com- 
munication between the epithelia and the lymph-spaces which reach 
into the connective-tissue sheath of the gland. As a result, the lymph 
flows freely among the secreting elements of the gland and its duct. 

Fig. 20. 




Thin section of the skin of a finder, removed at the site of a sweat-pore. Magnified 150 
diameters. The cavities or spaces seenin the epidermis are. some, apparently uncolored ; others 
arc blackened by the action of osmic acid npon fat originally contained in either cells or spaces 
between the latter. The effect is due to excretion of fat by the coil-glands, and the condition 
shown is not exhibited in all sections of the skin made at the same level. It is probably transi- 
tory, and is most apparent when the skin is macerated by sweat. 



This lymph, loaded with fat, streams away from the coils, and before it 
reaches the lymphatic trunks its fat-globules are filtered away in the 
subcutaneous tissue. 

Odorous Emanations from the Skin. — The skin of the human 

jbody in health is the constant source of odorous emanations, which, in 

pathological conditions, may greatly be increased or otherwise changed. 

The nature and exact sources of these emanations are as yet imperfectly 

understood. Were they exclusively volatile, gaseous, or vaporous, even 

though capable of condensation upon external bodies, this would scarcely 

explain the well-known fact that some of the lower animals are capable 

of tracing the track of a human being for miles over a wind-swept 

'path until the soil pressed by the foot is covered with water. There 

is strong reason to believe that these emanations are vehicles by which 

certain contagious and infectious diseases are transmitted from one 

individual to another. They at times contain living matter derived 

]from the protoplasm of the body, and are capable of conveying bacteria 

in compact masses and in enormous quantities through the atmosphere 

when it is agitated by a current of air. Some of the schizomycetes 



48 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 



weigh but one-ten-billionth of a milligramme, and are transported 
through space in the most attenuated of media. These emanations are 
properly regarded as having their origin in the secreting system of the 
skin, but in what proportion the several secreting glands participate in 
their production it is difficult to establish. The sweat at times, even 
to human nostrils, exhales a distinct odor, though, as before indicated, 
to what extent this is due to the admixture of sweat with sebaceous 
material it is difficult to determine. Peculiarly fetid and disgusting 
odors occasionally originate in chemically altered sebum exuded in 
regions of the body where the influence of the sweat-secretion must 
be, from the locality under examination, partly eliminated. 



NAILS. 

Nails are dense, elastic, and translucent concavo-convex plates, or 
shells, of horny tissue, placed upon the dorsum of the terminal extrem- 
ities of the distal phalanges of the fingers and toes. They result from 
an oblique invagination of embryonal epidermis, with modification of 
the keratinization-process at the level of the invagination (Darier). 
Each nail has a free border at the distal portion of the pulp of the 
digit, with sides and proximal borders let into distinct furrows of the 
skin. The convex surface of the nail is exposed ; the concave, regard- 
ing the phalanx, is implanted upon the nail-bed beneath. 




Vertical section of one-half of nail and matrix : a, nail-substance ; 6, horny layer ; c, mucous 
layer; d, papillae of corium; e, nail-furrow destitute of papillae; /.horny layer of the ungual 
furrow rising above the nail ; g, papillae of skin of dorsal surface of the finger. 

In the embryo the first change looking to the formation of a nail 
consists in a peculiar smoothness and brilliancy of the epidermis cov- 
ering the dorsum of the distal phalanges. Later, an epithelial ridge 
or line, with a groove in front of it, traverses the tip of the finger. 
Thus, three regions are defined : the region behind the ridge, the nail- 
wall ; that in the groove, the nail-bed ; and that in front of the groove, 
the pulp of the last phalanx of the digit. A collection of large prickle- 
cells at the orifice of the nail-fold soon furnishes the first trace of the 
rudimentary nail. Mature nail-cells finally push forward between the 
prickle- and horny layers of the nail-bed, which, by fan-shaped bundles 



NAILS. 49 

of follicles, is firmly united to the periosteum of the phalanx. Lastly, 
a thin plate of horny material with a free edge is visible externally in 
the fingers and toes of the newborn child. 

In the adult, Avhat is termed the Matrix of the nail is the tissue 
from which springs the horny plate. The cells of the matrix are cyl- 
indriform below and flattened superficially, with a fibrillary structure, 
and, instead of a stratum granulosum, are supplied with a layer of cells 
of brownish color charged with a keratogenous substance. The matrix 
is separated into, first, a posterior part, filled with from three to six 
rows of papillae; and next, in advance of this, a lenticular space with 
curved borders, the anterior limit of which corresponds with the an- 
terior border of the lunula. The area included in these two divisions 
is provided with papillae grouped in symmetrically converging ridges, 
decreasing in size as they pass forward. This forms the matrix of the 
nail. Further forward, the Nail-bed proper — in other words, the 
tissue that supports, rather than produces, the horny plate — is com- 
posed of higher ridges of papillae, the grooves and summits of which 
are covered with prickle-cells, and the height of which is uniformly 
maintained as they stretch forward toward the pulp of the finger. 

The Nail-fold, crescentic in shape, clasps the nail posteriorly and 
laterally. It is formed of connective tissue, the bundles of which are inter- 
penetrated by numerous coil-glands and fat-columns. The epidermis 
beneath the nail exhibits prickle-, granular, and horny layers. As the 
nail is gradually liberated from its bed both at the sides and point the 
cornification of the horny layer becomes more complete, so that finally, 
as the nail-plate is pushed forward, it no longer rides over the cells of 
the rete, but over a completely cornified tissue. 

If the pulp of a nail-bearing phalanx be pressed with moderate 
force against any firm object, the naked eye can detect upon the sur- 
face of the nail, just behind its free border, a yellowish-white band, 
convex anteriorly and somewhat increasing in width laterally. This 
line is also visible when no pressure is exerted upon the digit, its 
width varying under the conditions described. This border represents 
the space in which the three layers of the epidermis from the skin of 
the point of the finger, viz., the horny, the granular, and the prickle- 
layer, successively come in contact with the under surface of the nail. 

The Lunula is the relatively light-colored space extending from the 
middle part of the nail-fold posteriorly to its well-defined convex bor- 
der in front. After artificial removal of the nail-fold the lunula is seen 
to extend to the posterior and enclosed border of the nail-plate. It, 
therefore, represents that part of the matrix of the nail not concealed 
by the nail-fold. Its color is not due to absence of vascularity, but is 
owing solely to the relative opacity of the keratogenous cells which are 
concerned in the production of the horny threads that form the nail. 

The Nail (True Nail, or Nail-plate) originates only from the 
floor of the nail-fold as far forward as the anterior edge of the lunula. 
As to its formation, it may, therefore, be imagined as springing from its 
matrix vertically in the form of an involuted, shield-shaped plate, its 
convexity regarding the proximal phalanx. It may then be viewed 
as pressed downward over its nail-bed in front, with partially unfolded 
4 



50 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 



edges enwrapped by the epidermis of the sides, the narrowed point 
of the shield, elongated when untrinimed, projecting at some distance 
beyond the tip of the finger. 

With this conception it is easy to understand that the nail is con- 
stituted of horny filaments, or coherent strata of cornified cells, passing 
from the matrix or floor of the nail-fold. The upper surface of the 
nail grows, therefore, from the bottom of the nail-fold ; the under sur- 
face, from the lunula ; and the intermediate layers proportionately from 
the parts between, that interlock with corresponding grooves on the 
upper face of the bed. 

Fig. 22. 




Implantation of a nail at its border : P, papillee decreasing in size toward the middle line : 
R, rete mucosum, which broadens toward the border of the nail, and forms irregular prolonga- 
tions; R', E, epidermal layer; N, plate of the nail. Magnified 500 diameters. (After Heitzmann.) 



Unlike the hairs, the growth of the nails, when not modified by 
traumatism or disease, is continuous and without definite limit during 
the life of the individual. The growth is from the matrix to the free 
border, more actively in the young than in the old, and in summer than 
in winter. From one hundred to one hundred and sixty days are 
required for reproduction of an entire finger-nail, and about three times 
that period for the nail of a toe. The uncut nail is produced in the 
form of an elongated, pointed, claw-like talon. 

Nails are extremely sensitive to even moderate perversion of sys- 
temic nutrition ; and either in loss of brilliancy and polish or in 
deeper structural alterations betray evidences of changes in the health 
of the individual. 



II. -GENERAL SYMPTOMATOLOGY. 



In cutaneous, as in other, diseases the clinical signs or symptoms 
of a morbid process are those by which a disease is recognized alike 
by the patient and the physician. These signs and symptoms are di- 
• vided into subjective and objective : the former are those appreciated 
by the patient alone in consequence of his sensations ; the latter are 
j those detected by the eye and the touch of another who undertakes the 
1 investigation of the disease. It should be remembered, however — and 
this is a matter of some importance in this connection — that there are 
\ manifested to the eye and touch of the patient many objective signs 
i which are liable to be interpreted or misinterpreted by him, with con- 
sequences not to be ignored. 

SUBJECTIVE SYMPTOMS. 

The purely subjective symptoms of a disease of the skin are those 
manifested to the patient by sensations other than those connected with 
vision and his own sense of touch. They include sensations of itching, 
smarting, tickling, pricking, and burning ; sensations as of increased or 
diminished susceptibility to the contact of foreign bodies ; of increased 
or diminished temperature ; pain in various grades of severity ; and 
disordered sensations, such as those suggesting the crawling of insects 
| over the part, the passing of currents of hot or cold vapors or liquids, 
I and the compression of portions of the skin as by cords, bands, or 
j closely fitting plates. The character of the subjective sensations ex- 
perienced by a patient often proves an aid to the physician in recogniz- 
j ing the nature, not merely of a present disease, but also of one which 
has preceded. Thus, the sensation produced by an attack of erysipelas 
is rarely an itching, while the latter is highly characteristic of eczema 
I and scabies ; the pain of zoster and the tingling of urticaria being dis- 
tinctly different, not only from each other, but also from the subjective 
symptoms named above. 

OBJECTIVE SYMPTOMS. 

The study of the objective symptoms of a cutaneous disease is of 
paramount importance. In no respect does the skilled physician so 
distinguish himself from one who is unskilled as in ability to recognize 
the typical or atypical objective features presented in diseases of the 
j skin. This study is one which no diagnostician can safely neglect, and 
I its rewards are precious in every department of medical science. These 
symptoms are spread before the eye, and their legibility increases with 
every hour of careful observation, 

51 



52 GENERAL SYMPTOMATOLOGY. 

These signs of skin-disease — or, more literally, skin-injury — are 
called " lesions " (efflorescences, elements of an eruption), and it is 
usual to classify them as primary and secondary. Such division, how- 
ever, is open to criticism, since, in point of time merely, some of the 
so-called " primary lesions " of the skin become in turn secondary and 
even tertiary. Thus, a papule which might at one time be called 
" primary," may be transformed wholly or in part into a vesicle, which 
thus becomes a secondary lesion, and such vesicle again, in the evolu- 
tion of a disease, may become a tertiary pustule, and the latter finally 
may result in a quaternary crust. In the following pages these 
symptoms of skin disease are distinguished as elementary and con- 
secutive. 

Elementary Lesions. — In describing the average size of cutaneous 
lesions it is less convenient to state their measurement in fractions of 
a line or of a millimetre than to convey an approximate idea by a 
comparison with familiar objects of relatively fixed dimensions. The 
objects usually selected for this purpose, beginning with the smallest, 
are seeds of the poppy, mustard, and rape ; the coffee-bean ; the pea ; 
the bean ; the cherry ; the finger-nail ; the chestnut ; the horse-chest- 
nut ; the egg of the hen and of the goose ; the orange. To these may 
also be added the point and head of a pin. The student will find it 
useful to familiarize himself with the size of the small seeds men- 
tioned, that their names may at once suggest to him the relative size 
of the lesions with which they are compared. 

Maculae (spots, or stains) are generally circumscribed 
alterations in the color of the integument, differing in 
size, shape, hue, and duration of the dyschromia, and un- 
accompanied by elevation or depression of the skin-sur- 
FACE. 

Maculae may be due to arterial or venous hyperemia, to the escape 
of the coloring-matters of the blood into the skin, to acquired and 
congenital telangiectasis, and to pigment-anomalies. Examples of 
maculae are to be found in the exanthematous rashes (measles) ; in 
localized hyperemia of the capillary plexuses of the corium, disappear- 
ing in various degrees according to the pressure exerted on the part 
(rosacea) ; in visible acquired development of blood-vessels in the 
skin (telangiectasis) ; in congenital vascularization of the surface (naevi) ; 
in variously colored blood-extravasations and stases (purpura) ; in 
stains produced by contact with dyes (hand-workers in anil in) ; and 
in pigmentary changes such as those produced by solar heat (freckles) 
or by leprosy. 

Extensive non-circumscribed changes in the skin-color are seen in 
the course of several general disturbances of the economy, as in yel- 
low fever, cancer, chlorosis, albinism, Addison's disease, argyria, and 
icterus. 

Spots of various color and device are also produced by the inten- 
tional or accidental introduction of pigmented particles beneath the epi- 
dermis, as by the process of tattooing, the explosion of gunpowder, etc. 

Maculae exhibit a wide variation in color from a rosy pink to a 
chocolate brown or even a black. This difference has suggested the 



OBJECTIVE SYMPTOMS. 53 

employment of such descriptive terms as roseola, erythema, and 
purpura, which, unfortunately, serve to distinguish both the features 
of diseases and the diseases themselves. 

A macula which encircles another lesion, as, for example, the halo 
around a vaccine vesicle, is called an " areola." Linear hemorrhagic 
streaks are called " vibices " ; punctate and larger extravasations of 
blood are termed " petechia " and " ecchymoses." 

Papula (papules) are solid or compressible, ephemeral 
or persistent, circumscribed projections from the surface 
of the skin, varying in size from that of a poppy-seed 
to that of a coffee-bean. 

These exceedingly common skin-symptoms vary greatly in their 
shape, color, location, career, and significance. Thus, they may be flat- 
tened at the apex, acuminate or pointed, conical, rounded, or depressed 
at the summit to form an umbilication ; they may be pale, rosy, dark 
or lurid red, purplish, or even blackish ; they may develop in transi- 
tory or persistent processes ; they may be transformed into lesions 
containing fluids ; may desiccate and furnish scales either at apex or 
base ; may degenerate into ulcers ; or may enlarge into tubercles or 
tumors ; may be scratched, torn, or rubbed so as to lose their typical 
appearance ; may come and go ; may be sensitive to sudden changes in 
the blood-current, and yet be persistent. 

The mixed forms described above are generally named vesico-pap- 
ular or papulo-vesicular, papulo-squamous, papulo-pustular lesions, etc. 

Lesions which simulate the papule, and which, though described 
under that title, really belong to another category, are the small, semi- 
solid elevations of the surface that form at the orifices of the ducts of 
the cutaneous glands and follicles. Thus, they may consist of little 
heaps of epidermis about the hair-follicles (lichen pilaris, keratosis 
pilaris), or of inspissated sebum collected in one of or in all the acini 
of the sebaceous glands (comedo). 

The concomitants of an eruption of papular type also vary. Thus, 
there may be a febrile process, or extensive infiltration of the skin 
about and beneath the papules (prurigo), or itching of the most intol- 
erable character (eczema papillosum), or production of trifling sensa- 
tions of annoyance, as a slight burning without other subjective symp- 
toms (acne, lichen planus). 

Papules transformed into moist lesions become covered with a crust. 
Papules scratched or torn by the finger-nails usually betray the fact in 
the minute and flat blood-scales dried upon their surface. Papules which 
ulcerate may be followed by scars, and those which have undergone 
the process of involution may be followed by macular sequelae. 

POMPHI (URTIG^, WHEALS) ARE MORE OR LESS TRANSITORY, 
ROSY RED AND WHITISH, IRREGULAR SHAPED AND SIZED ELEVA- 
TIONS OF THE SURFACE OF THE SKIN, PRODUCED BY BLOOD- 
STASIS IN SPASM OF THE VESSELS, ACCOMPANIED BY A TINGLING 
OR A PRICKLING SENSATION, AND CHARACTERIZED BY RAPIDITY 
OF EVOLUTION AND FREQUENCY OF RECURRENCE. 

The typical wheal is seen in the disease known as " nettle-rash " 
(urticaria), in which closely packed, shining, roundish and whitish 



54 GENERAL SYMPTOMATOLOGY. 

pea- to finger-nail-sized elevations of the skin are visible, surrounded 
by a slightly rosy border. Wheals are firm to the touch, and ar- 
ranged in patches, circles, bands, gyrations, or striations, often disap- 
pearing in a brief time and recurring with or without a renewal of the 
cause. They are occasioned by a rapid exudation of serum into the 
rete or pars papillaris of the corium. This is due to clonic vascular 
spasm, producing irregularities in the lumen of the skin-capillaries, 
under the influence of the vasomotor nerves which supply a small 
area of the superior pars vascularis of the derma. The sensations pro- 
duced are stinging, burning, pricking, and itching. Wheals are often 
surrounded by an areola. 

" Giant "-wheals are such as have the dimensions of a hen's egg, or 
cover extensive areas of integument, as, for example, the entire surface 
of a buttock or a shoulder. 

Relics of disappeared wheals are usually transitory erythematous 
maculae, but in rare cases there is left a more or less deep pigmentation 
which slowly disappears (urticaria pigmentosa). 

At times the wheal-like condition is assumed by papillae, as also by 
lesions resulting from such traumatisms as the bites of insects, reptiles, 
horses, dogs, etc. 

TUBERCULA (TUBERCLES) ABE CIRCUMSCRIBED, SOLID, GENERALLY 
INCOMPRESSIBLE AND PERSISTENT NODOSITIES OF THE SKIN, VARYING 
IN SIZE FROM THAT OF A COFFEE-BEAN TO THAT OF A CHERRY. 

It should be carefully noted that tubercles occurring in diseases of 
the skin bear no relation whatever to the nodules having the same name 
which develop in pulmonary tuberculosis. The dermatological title 
relates solely to the size of the lesion. 

Tubercles may largely be projected from the free surface of the 
integument, or be deep seated in the skin, and but a small portion 
become evident to the view externally. Their varieties as to shape, 
color, size, and other features correspond in great part with those de- 
scribed in connection with papules. They may be attached by a broad 
base to the skin, or be pedunculated, or even pendulous. Their seat is 
usually in the deeper portions of the corium or in the subcutaneous 
connective tissue. Degenerating and ulcerating tubercles arc followed, 
as might be supposed in view of their volume, by considerable destruc- 
tion of tissue, and correspondingly in cases of repair by extensive 
cicatrices. Tubercles are seen in such diseases as fibroma, molluscum 
epitheliale, syphilis, leprosy, sarcoma, and cancer. 

Tubercles are often described as merely enlarged papules, but the 
distinction between these two forms of lesions will better be recognized 
when attention is paid to the particular portion of the skin in which 
each takes its origin. Papules spring oftenest from the superficial 
layers of the derma ; tubercles, from the deeper layers. At times a 
tubercle may project from the surface to a less extent than a papule, 
though its larger volume is evident as soon as the skin within which 
it has developed is handled. 

Tubercles due to a cellular infiltration may cease to be circumscribed, 
and by coalescence furnish a diffuse involvement of both the skin and 
the subcutaneous tissue. 



OBJECTIVE SYMPTOMS. 55 

Papulo-tuberdes are transitional forms assignable to either of the 
two lesions named. 

Phymata (tumores, tumors) are masses of solid tissue, or of 
solid tissue more or less commingled with fluids of variable 
consistency, differing in size, shape, color, and in the benig- 
nity or malignity of their career, located either within or 
beneath the skin, or, being attached to the skin, projecting 
from it to a variable extent. 

The mere fact that a lesion of the skin approaches hi dimensions the 
size of a tumor is in itself an element of gravity. Tumors may origi- 
nate in mere hyperplasia of the living matter; may consist of new 
formations of greater or lesser danger to the vicinage or to the general 
economy ; may be formed of blood-vessels or of hymphatic vessels, or 
of both in the same lesion ; may embody large fluid-containing cysts ; 
may be built up of nerve-tissue, fat, bundles of connective-tissue fibres, 
glandular elements, and indeed of any of the elements which exist 
physiologically in the human integument. 

Examples of tumors are seen in fibroma, sarcoma, carcinoma, and 
rhinoscleroma. 

Vesicul.e (vesicles, phlyctene, phlyctenule) are acumi- 
nate, ROUNDED OR FLATTENED ELEVATIONS OF THE HORNY LAYER 
OF THE EPIDERMIS AVITH LIMPID, LACTESCENT, OR SANGUINOLENT 
FLUID CONTENTS, VARYING IN SIZE FROM THAT OF A POPPY-SEED TO 
THAT OF A COFFEE-BEAN. 

Typical vesicles are seen in the minute, transitory lesions occurring 
in the vesicular form of eczema. They are usually filled with a clear 
serum. Variations from this type, however, are common. Thus, they 
may be either flattened, acuminate, roundish, umbilicated, or conical ; 
may be fully distended or partially collapsed upon their contents ; may 
have a short or long duration ; may be distended with a milky, chylous, 
or blood-stained fluid ; may be opalescent, yellowish, reddish, or black- 
ish in color ; several may coalesce to form a many-chambered bulla. 
One or several may undergo transformation into pustules or bullae. 
Vesicles may terminate by accidental or spontaneous rupture, their 
contents freely flowing forth upon the surface of the peripheral integu- 
ment ; or they may desiccate to a crust ; or may even terminate by 
one of the ulcerative processes. They may or may not be accompanied 
by pruritus. Minute vesicles, which are merely the external apices of 
large-chambered accumulations of fluid beneath, occasionally form upon 
the surface of the skin. Such are seen in the course of lymphangiec- 
tasis. 

PUSTULE (PUSTULES) ARE CIRCUMSCRIBED CUTANEOUS ABSCESSES, 
COVERED WITH AN EPIDERMAL ROOF-WALL, AND VARYING IN SIZE 
FROM THAT OF A MILLET-SEED TO THAT OF A FILBERT. 

The typical pustule contains pus, and is colored yellowish, yellowish 
green, or brownish green, according to the admixture of its contents 
with blood. The pus being an inflammatory product, necessarily indi- 
cates the occurrence of an inflammatory process at the base of the 
pustule. Pustules, like vesicles, may be roundish, acuminate, globoid, 
conical, or umbilicated, and surrounded by an inflamed or normal 



56 GENERAL SYMPTOMATOLOGY. 

integument ; may be superficial or be deep-seated ; may terminate by 
rupture or by desiccation ; may or may not be followed by an ulcer 
and ultimate cicatrix. They may be seated either upon the free surface 
of the skin, or at an orifice of a follicle, in which case they represent 
an inflammation with purulent product in the duct or the gland 
beneath. 

Pustules may originate as such, or as a consequence of transforma- 
tion of vesicles, or after a change in a papule, which may thus come to 
have a purulent apex. According to Auspitz, they invariably originate 
from vesicles. Pustules often result in the formation of crusts, the 
latter varying in color according as the pustules from which they orig- 
inated contained a clear serum or blood. 

Transitional forms between vesicles and pustules are termed vesico- 
pustules. Pustules of a large size, resting upon an indurated, engorged, 
and elevated base are often called " ecthymatous." 

Pustules are seen in syphilis, variola, eczema, scabies, acne, and many 
other cutaneous diseases, including several forms of dermatitis medica- 
mentosa. Many contain pus-cocci ; some furnish a " neutral," or pseudo-, 
pus destitute of micro-organisms. 

Bullae (blebs) are superficial or deep-seated elevations 
of the skin having fluid contents, differing in color, shape, 
and career, and varying in size from that of a coffee-bean 
to that of a goose-egg. 

Blebs have been described as large vesicles ; but this fails to define 
exactly their pathological character. Like vesicles, they may contain 
serum, lymph, blood, or pus, and may variously be colored according, 
to the degrees in which their contents become visible through a semi- 
transparent roof-wall. They may be globoid, hemispherical, oval, 
crescentic, semi-crescentic, or conical, and may even exhibit angles. 
They may be seated upon an apparently unaltered or an evidently 
morbid integument ; and may or may not present a peripheral areola. 

Bullae may persist or may rupture ; may desiccate or may degenerate 
into ulcers ; may collapse after the escape of their contents, and the 
roof-wall become glued to the base from which it was originally raised. 
Bullae usually occur in extremely debilitated states of the system, and 
are, as a rule, of graver portent than other fluid-containing lesions of 
the skin. They occur in scalds and burns, in pemphigus, leprosy, 
erysipelas, syphilis, and moist gangrene. 

Consecutive Lesions. — Squamae (scales) are attached or 

EXFOLIATED EPITHELIAL LAMELLA WHICH HAVE BECOME APPRECI- 
ABLE AT THE SURFACE AS THE RESULT OF SOME MORBID PROCESS 
IN THE SKIN. 

There is constantly in progress over the superficies of the body 
physiological desquamation, the evidences of which are not pronounced 
in skins properly cleansed by ablution. In morbid processes, how- 
ever, desquamation may occur as a distinct symptom in various forms. 
Thus, the scales may be minute, fine, branny, dirty white or yellowish ; 
they may be large, pearly white, shining ; may be dry or fatty ; may 
be aggregated so as to resemble flaky pie-crust ; may exfoliate in 
extensive sheets, as from the entire sole of the foot or the palm of the 



OBJECTIVE SYMPTOMS. 57 

hand, or in glove-finger-like sheaths, as from the surface of a digit ; 
they may be scanty, scarcely perceptible, and so firmly attached as to 
require force for their removal ; they may fall spontaneously in a pul- 
verulent shower, being so abundant as to encumber the garments or the 
bed-clothing of the patient. 

Furfuraceous or pityriasic desquamation is that form in which fine, 
bran-like scales are shed from the surface. 

Scales are frequently intermingled Avith other lesions, often succeed- 
ing the latter. Thus, a papule may scale at its apex, or surround its 
base with a collarette of loosened epidermal plates, beneath or between 
which a macular stain is visible. Again, scales may develop from 
macule, tubercle, or tumor. Though generally conceded to be evi- 
dences of a dry and non-discharging disease of the skin, they are at 
times accompanied or succeeded by moisture of the part affected. 

The term scales is sometimes applied to the flattened plates of dried 
sebum that form on the scalp and on portions of the trunk in sebor- 
rhea sicca. 

Scales occur in eczema, psoriasis, pityriasis, ichthyosis, syphilis, and 
in several of the parasitic diseases of the skin. 

Crustje (crusts) are relics of the desiccation of patho- 
logical PRODUCTS OF THE SKIN. 

Crusts never occur as primary symptoms of disease. When formed 
by the desiccation of serum only they are of a yellowish, straw-yellow- 
ish, or reddish-yellow hue ; when composed largely of dried pus they 
are colored greenish or greenish yellow ; and when there has been an 
admixture of blood they are usually brownish or blackish. At times 
they suggest in appearance gum, honey, or Venice turpentine ; in 
shape they may have the form of the concavo-convex lid of a watch- 
case ; in color and shape they may resemble the half-shell of an oyster 
or the carapace of a small turtle. They may be delicate and thin, 
bulky and thick, friable or mealy ; may be firmly attached to the sub- 
jacent tissues or readily separable ; may cover a sound though tender 
and reddened epidermis ; may conceal a superficial or a deep, foul- 
based ulcer, by secretions from beneath which they are raised above 
the plane of the skin and increased in thickness ; they may be circum- 
scribed and no larger than a small finger-nail ; may envelop an entire 
limb or organ, as the leg or the penis ; or, finally, may be so irregu- 
larly disposed among other lesions — papules, pustules, excoriations, and 
open ulcers — that it is difficult to define their outline, or even to recog- 
nize their identity. Crusts formed of dried sebum are greasy to the 
touch, dirty yellowish in shade, and usually seated upon a non-infil- 
trated base. 

Crusts are common in eczema, syphilis, leprosy, seborrhea, and in a 
large number of other diseases of the integument. 

Excoriations are superficial solutions of continuity, 
usually involving portions of the skin affected with pru- 
ritus, and resulting from mechanical violence. 

Excoriations, in appearance among the most trivial of skin-lesions, 
possess a value from the diagnostic point of view which can scarcely be 
overestimated. They occur as striated, linear, punctate, circular, or 



58 GENERAL SYMPTOMATOLOGY. 

irregularly shaped, furrowed wounds, at times involving areas of flat 
surface, oozing with serum or blood, covered with dried blood or crusts, 
yellowish or reddish in hue, and for the most part both induced and 
accompanied by severe pruritus. They may coexist with hyperemia 
and infiltration of the skin beneath, brought on by the irritative char- 
acter of the continuous, or, more frequently, interrupted, cause by 
which they were begotten. 

Excoriations become significant according as they indicate scratch- 
ing, tearing, or other species of wounding by the finger-nails, and the 
rubbing of portions of the integument with foreign bodies. In the 
former case they are significantly recognized in those portions of the 
body most accessible to the hands, though in the case of eczematous 
children and infants they may originate by the rubbing together of the 
knees, or the rubbing of one leg by the feet and toes of the other leg. 
The loss of tissue may extend deeper than the rete, at times invading 
the papillse of the corium, which bleed in consequence. 

Excoriations may occur without the appearance of other lesions, as 
in the disease called "pruritus"; but where itching is severe and 
induced by a cutaneous exanthem the lesions constituting the latter 
may be intermingled with, obscured by, or even obliterated by excoria- 
tions and the pathological processes to which they give origin. Thus, 
macules, vesicles, pustules, and papules may undergo change; and the 
recognition of the type of the existing disease may correspondingly be 
difficult. Excoriations are common in skins wounded by lice, bed- 
bugs, and gnats; in the subjects of eczema, scabies, intertrigo, and 
prurigo ; and in individuals with special sensitiveness of the integu- 
ment to the action of a medicament employed either internally or ex- 
ternally. 

Ehagades (fissures) are linear solutions of continuity, 
usually occurring in previously infiltrated portions of the 

SKIN. 

Fissures may extend to the derma, and invade yet deeper struct- 
ures; may be painful or the reverse; may be dry, secretory, or in- 
crusted; are often hemorrhagic, and usually are formed with sharply 
cut walls. They are of frequent occurrence in the vicinity of the 
articulations, in which situations they are induced or aggravated by 
the joint-movements stretching or tearing tissue the extensibility of which 
has been diminished by any morbid process. Fissures may terminate 
in ulceration ; they vary as to length, curve, and tenderness ; they are 
often exquisitely painful, and greatly complicate the skin-disease in 
which they form; they may follow the curve traced by the boundaries 
of bodily organs near which they occur — as, for example, the line of 
the posterior junction of the ear with the head, or that of the breast 
of a woman with the thoracic wall upon which it rests. 

Fissures occur in eczema, syphilis, dermatitis, and lichen ruber. 

Ulcera (ulcers) are losses of substance resulting from a 
previous pathological process involving the corium, and, in 
some cases, the subcutaneous tissue. 

Cutaneous ulcers differ greatly in size, shape, color, edges, base, 
career, and, indeed, in all their characteristics. Every ulcer has an 



OBJECTIVE SYMPTOMS. 59 

outline, a base, a floor, edges, and a secretion. The outline may be 
circular, crescentic, reniform, ovoid, serpiginous, or with horseshoe- 
like contour. The base, or underlying tissue, may be soft, supple, 
indurated, or in a state of active inflammation, with consequent infil- 
tration. The floor may be glazed, shallow, deep, excavated, cup- or 
funnel-shaped, "worm-eaten," crateriform, sloughy, covered with a 
tenacious or a readily removed secretion, granular, puriform, or hem- 
orrhagic. The edges may be clean-cut, having a punched-out appear- 
ance, undermined, everted, ragged, irregular, or contracting, with a 
whitish inner border of advancing cicatrization. The secretion may 
be scanty, limpid, puriform, profuse, ichorous, and odorless, or exhale 
an offensive stench. Ulcers may be so crust-covered as to be invisible, 
or so exposed and erosive in action as to render the affected surface in 
the highest degree unsightly. They may be acute or chronic, insensi- 
tive or productive of intense pain; may heal by cicatrization, remain 
open for a lifetime, or prove fatal either by destruction of parts essen- 
tial to life or by exhaustion of the vital forces. 

Cicatrices (scars) are new-formed substitutes for lost con- 
nective tissue. 

Scars never succeed excoriations, fissures, or other solutions of con- 
tinuity in the skin that have not penetrated as far as the derma and 
resulted in destruction of a portion of the elements of which the derma 
is built up. They possess the highest importance for the diagnostician, 
since they point invariably to a pathological process the career of which 
is terminated, the characteristic features of which termination they fre- 
quently embody. They may be regarded as the special and persistent 
imprints upon the integument of the serious disorders from which it 
has suffered. 

To a certain extent, as already shown, scars retain traces of the spe- 
cial peculiarities of the lesions, and even of the diseases, which they 
succeed. The identification, however, of the individual predecessor in 
each instance is, in the present state of our knowledge, not always pos- 
sible from a study of cicatrices alone. The extent of knowledge in 
this direction, however, is rapidly increasing; and in many cases the 
certainty thus acquired is of incalculable value to the diagnostician. 

Scars are remarkable for their tendency to contraction and gradual 
decoloration. They may be minute, punctate, extensive in area, 
attached to underlying tissues, depressed, raised above the plane of the 
peripheral skin, seamed with furrows, pliable and soft, indurated, trav- 
ersed by ridges, knotted, or as irregular in contour as the ulcers 
already described. They may extend in digital, linear, or annular pro- 
longations toward contiguous portions of the skin, and by subsequent 
contraction induce considerable distortion and deformity. Thus, they 
may drag down an eyelid, and ectropion ensue; may glue the lobe of 
an ear to the cheek ; may evert lip or nostril. When recent they are 
usually reddish in tint ; when older they may be pigmented in centre 
or at circumference ; or, as is common, may exhibit a gradual decolora- 
tion centrifugal in its progress. They may be the seat of pain from 
an entrapped nerve-filament ; may reopen to ulceration ; or may be 
unaccompanied by subjective sensation. Not rarely they become the 



60 GENERAL SYMPTOMATOLOGY. 

source of keloid. Scars are unprovided with hairs, papillae, or the ori- 
fices of sweat-pores and sebaceous gland-ducts. As implied in the 
definition given above, scars may result from any disease or injury 
of the skin that involves loss of connective-tissue elements in the 
corium. 

Unclassified Lesions. — To the several lesions defined above Bazin 
adds, as elementary forms, the mucous patch of syphilis, the cuniculus, 
or furrow, produced in the skin by the Acarus scabiei, and the sulphur- 
colored crusts of favus. Among the elementary lesions of the skin, 
Brocq includes the gumma, or firm, deeply situated, often subcutaneous 
mass commonly degenerating centrally rather than, as may the tubercle, 
from without inwardly ; while among the consecutive (so-called " second- 
ary ") lesions of the skin the same author considers " lichenization " or 
" lichenification." These are terms chiefly employed by French writers 
to designate the changes in the skin produced by long-continued ex- 
ternal irritation, the thickened and infiltrated integument assuming 
a yellowish-brown or reddish-brown tint, the exposed surface being 
studded with pinhead, pin-point, or slightly larger, shining and flattened 
isolated elevations, with delicate furrows separating each from the 
other. These, however, are not general, but special features of 
individual disorders, and are best studied in connection with the 
latter. 

The elementary lesions of the skin are termed by Auspitz anthe- 
mata ; groups of such lesions, synanthemata ; and, in accordance with 
common usage, generalized eruptions affecting the entire surface of the 
body, exanthemata. The word erythanthema is used to describe groups 
composed of several of the elementary lesions of the skin, as, for ex- 
ample, of papules, vesicles, and pustules rising from a common red- 
dened and hypersemic base. 

In addition to the names of the lesions of the skin just enumerated, 
certain peculiarities of cutaneous symptoms are described in qualifying 
terms which here require definition. They relate chiefly to the color, 
shape, distribution, and method or period of evolution of lesions as 
they are observed in individual cases. The more important of these 
terms, as used by modern writers, are alphabetically arranged below, 
with a brief explanation appended to each. 

Abdominalis. Located on the abdominal surface. 

Acquisitus. Acquired. 

Actjminatus. Having a pointed apex. 

Acutus. Of acute course. 

Adultorttm. Occurring in adult years. 

JEstivalis. Occurring in the summer season. 

Aggregates. Collected in patches. 

Agrius. Acute, or angry in appearance. 

Albidus. Of whitish color. 

Angiectaticus. Vascularized. 

Annularis. ) T , T t f 

Annulatus. } In the form of a rm S- 

Apyreticus. Unaccompanied by fever. 

Areatus. Occurring in areas. 

Artifictalis. Producible artificially. 

Asymmetricalis. Of different distribution on the two lateral halves of the bodv. 



OBJECTIVE SYMPTOMS. 61 

Autumnalis. Occurring in the autumn. 
Brachialis. Occurring on the surface of the arm. 
Cachecticorum. Occurring in debilitated subjects. 
Capitis. Occurring on the head, usually the scalp. 
Cavernosus. Large chambered. 
Chronicus. Chronic in course. 
Circinatus. Of circular outline. 
Circumscriptus. Having a definite contour. 

L-onfertus. \ Arranged in close proximity, with coalescence of lesions. 

Contagiosus. Capable of transmission by contagion. 

Corporis. Occurring on the surface of the body ; employed usually to designate an 

eruption upon the trunk, as distinguished from that on the head or the extremities. 
Crustosus. Crusted. 

Crystallinus. Of crystalline appearance. 
Diffusus. Irregularly disposed. 
Discretus. Having isolated lesions. 

Disseminatus. Disseminate ; without regularity of distribution. 
Eruption. Is used of the totality of all patches and lesions upon the person of 

one individual. 
Erythematosus. Having a reddish blush. 
Essentialis. Idiopathic. 
Exfoliativus. Having a tendency to exfoliation or shedding from the surface of 

the body. 
Exulcerans. Exhibiting lesions with a tendency to superficial ulceration. 
Facialis. Located on the face, usually as distinguished from the scalp. 
Favosa. Displaying crusts of favus. 
Febrilis. Accompanied by a febrile process. 
Femoralis. Occurring on the surface of the thigh. 
Fibrosus. Composed of fibrous tissue. 
Figuratus. Having a figured appearance. 
Flavescens. Of yellowish hue. 
Foliaceus. Kesembling a leaf or leaves. 
Follicularis. Concerning the cutaneous follicles. 
Fungoides. Resembling a fungus. 

Furfuraceus. Exhibiting numerous fine, bran-like scales. 
Guttatus. Of the size of a drop of water. 
Gyratus. Having a serpiginous or gyrate outline, which is usually the result of a 

coalescence of imperfect circles or semicircles. 
Herpetiformis. Vesicular or herpetic in type. 
Hiemalis. Occurring in the winter season. 
Humidus. Accompanied by moisture. 
Hypertrophicus. Characterized by hypertrophy. 
Hystrix. Having lesions projected or erected like quills. 
Imbricatus. With crusts or scales overlain like tiles. 
Impetiginodes. Pustular. 
Infantilis. Occurring in infancy. 
Intertinctus. Distinguished by color. 

Iris. Occurring in more or less distinctly defined concentric rings. 
Labialis. Occurring upon the surface of the lip. 
Lenticularis. Of the size of a small bean. 
Lividus. Deeply colored. 
Maculosus. Discolored. 
Madidans. Characterized by moisture. 
Marginatus. Having a defined margin. 

Medic amentosus. Produced by external or (more commonly) internal medication. 
Melanodes. Of blackish color. 
Miliaris. Of the size of a millet-seed. 
Mitis. Of mild, benignant type — the reverse of agrius. 

Multiformis. Exhibiting simultaneously several types of elementary lesions. 
Neonatorum. Occurring in the newborn. 
Neuriticus. Having nervous association. 
Nigricans. Of a black or blackish color. 

Nodosus. With development of nodes or tuberosities of the surface. 
Nummularis. Of the size of small coins. 



62 GENERAL SYMPTOMATOLOGY. 

Oleosus. Accompanied by an oily secretion. 
Palmaris. Occurring on the palms. 

Parasiticus' f Produced by an animal or a vegetable parasite. 

Patch. The aggregation of several isolated or confluent lesions. 

Phlegmonosus. Accompanied by deep-seated inflammation. 

Phlyct^enoides. Characterized by groups of small vesicles. 

Pigmentosus. Accompanied by pigmentation. 

Pilaris. Eelated to the hair. 

Plantaris. Situated on the soles of the feet. 

Planus. Flat. 

Polymorphous. The Greek equivalent of the Latin multiform. 

Pr^putialis. Situated upon the prepuce. 

Progenitalis. Situated upon the exposed mucous surfaces of the genitalia. 

Pruriginosus. Accompanied by itching. 

Pubts. Located upon the skin or hairs of the pubes. 

Punctatus. Occurring in dots or points. 

Rhagadiformis. Fissured, or tending to produce fissures. 

Rosaceus. Having a rosy or pinkish hue. 

Ruber. Red ; usually dark red in color. 

Scutiformis. Having the shape of a shield. 

Sebaceus. Concerning the sebaceous glands or their secretion. 

Senilis. Occurring in advanced years. 

Serpiginosus. Literally, creeping ; advancing in irregular gyrations. 

Siccus. Dry ; unaccompanied by moisture. 

Solitarius. Exhibiting an isolated lesion, or with isolated lesions. 

Symmetric alls. Similarly distributed on the two lateral halves of the body. 

Toxicus. Poisonous. 

Uniformis. Exhibiting lesions all of one type. 

Universalis. Affecting the entire surface of the body. 

Urticatus. Accompanied by wheals. 

Uterinus. With association of uterine disorder. 

Variegatus. Exhibiting several distinct colors. 

Vasculosds. Accompanied by vascular development. 

Vernalis. Occurring chiefly in the spring of the year. 

Versicolor. Exhibiting several shades of the same color. 

Vulgaris. Of the usual or commonly observed type. 



III. GENERAL ETIOLOGY. 



The study of the causes of skin-diseases gives a glimpse of the eti- 
ology of diseases in general. In the lowest representatives of life the 
greatest dangers to existence originate in exposure to assault from other 
and stronger representatives in search of their prey — in other terms, 
an external danger. In man, the highest representative of the animal 
scale, the perils of existence are complicated by his social necessities 
and his artificial methods. He can never, however, at any period of 
his existence, divest himself from the necessity of exposure to external 
peril. The plan of his organs and the play of his normal activities are 
perfect, even to the recovery from all but mortal injury aud repair of 
moderate loss. The struggle for existence of the ideal man is intended 
to be with that which is without ; his body meanwhile furnishing him 
with a comfortable tenement and a fair fortress. In the purview of 
nature there should be no internal revolt. When such occurs it is 
usually the result of his ignorance, his folly, or his vice. 

Viewed comprehensively the causes of diseases of the skin are seen 
to be numerous ; extremely different from each other ; some effective 
singly, others either alone or in combination Avith similar or different 
agencies ; some operating slowly, others rapidly ; some operating from 
within the body, others from without ; some directly, yet others only 
very indirectly, exerting their forces upon the integument. The results 
are as diverse as the causes themselves. Some dermatoses produced by 
a single cause are similar in symptoms ; others, originating from like 
causes, present scarcely the slightest resemblance to each other. It is 
from a study of this interesting field that much of the experience of 
the diagnostician is derived. 

For convenience of classification, it is well to consider the causes of 
diseases of the skin : first, as internal agencies ; secondly, as external 
agencies ; thirdly, as agencies which modify diseases produced by any 
of the original factors capable of their production. 

INTERNAL CAUSES. 

Heredity. — Some cutaneous disorders, such as syphilis, are capable 
of transmission to a second generation. The prevalent doctrines, how- 
ever, respecting the inheritance of a large number of cutaneous affec- 
tions are without question erroneous. Still the fact remains, that 
whether keratosis, psoriasis, and some other diseases not recognizable 
at birth (as may be the lesions of syphilis), are at times the result of 
inheritance, it is certain that a predisposition to diseases of many kinds 
is in perhaps the majority of cases transmitted to a second generation. 

63 



64 GENERAL ETIOLOGY. 

The weakness or vulnerability of a given organ of the body renders it 
especially liable to external or internal sources of damage, and may be 
strictly inherited. 

Visceral and Constitutional Disorders. — The group of affections 
commonly included in the language of the schools as within the field 
of " inner medicine " furnishes a large list of causes effective in the 
production of cutaneous maladies. Among visceral disorders may be 
named those of the kidneys (Bright/ s disease, albuminuria, diabetes), 
giving rise to pruritus, angioneurotic cedema, eczema ; of the uterus, 
giving rise to certain pigmentary changes in the skin ; - of the central 
or peripheral nervous system, as in urticaria, herpes, hemiatrophia, prur- 
itus, alopecia ; of the alimentary canal, producing eczema, acne, urti- 
caria, etc.; of the adrenals, as in morbus Addisonii ; and of the stomach, 
as in several of the gastric dyspepsias, which are capable of producing 
urticaria, erythema, acne, and rosacea. 

Among the constitutional affections capable of originating disorders 
of the skin may be named glycosuria (apart from renal diabetes), which 
may be productive of glycosuric xanthoma ; syphilis, which is respon- 
sible for an extended list of dermatoses ; gout and rheumatism, which 
influence to a remarkable degree the oncoming of certain eczemas of 
the anal and other regions, multiform erythema, acne rosacea, and 
purpura ; and disorders of the respiratory tract, some of which (e. g., 
asthma) are well known to have a distinct relation to eczematous out- 
breaks, with which their attacks may alternate. 

The Nervous System is responsible for a number of dermatoses. 
The nerve-centres, nerve-trunks, and nerve-terminals may largely influ- 
ence inflammatory, congestive, and atrophic states ; cerebral, spinal, and 
sympathetic nervous changes (trauma, new-growths, simple inflammatory 
thickenings, etc.) may be directly or indirectly concerned in attacks of 
pemphigus, zoster, scleroderma, urticaria, hyperidrosis, alopecia, and 
even grave ulceration of the skin. Pigment-changes in the skin and 
its accessories (hair and nails) have been produced by such causes. 

Psychical perturbations, as in the shock following traumatisms, ter- 
ror, bereavement, great and prolonged anxiety, and even the excite- 
ments of success in war and business have a demonstrable effect both 
on the nutrition and color of the skin and of the hairs and nails, as 
well as in the production of exanthemata, such as bullae, vesicles, and 
several types of dermatitis. In the same connection may be named 
the results of maternal impressions upon the foetus, which, among the 
ignorant and to an extent also among men of science, are believed to 
be responsible for so-called " mother's marks," including pigmentary, 
papular, and vascular nsevi, as well as the larger lipomatous tumors 
associated with hairy moles. The disorders designated "hysterical 
neuroses " constitute a small group of affections occurring chiefly in 
young and hysterical women, characterized by the occurrence of vesic- 
ular and bullous lesions, some taking on a gangrenous aspect, others 
exhibiting oddly arranged and defined streaks of dermatitis, to which 
latter the suspicion justly attaches that the lesions have been in great 
part produced by the patients themselves. 

The Sexual System of both men and women, especially in young 



INTERNAL CAUSES. 65 

subjects, may be a source of cutaneous disorders. Among them may 
be named the seborrheas, acnes, and comedones, often aggravated by 
menstruation and by perversion of function in both sexes, progenital 
and menstrual herpes, pemphigus virginum, and certain of the erythem- 
ata. The several cutaneous affections recognized in the pregnant con- 
dition are often unquestionably associated with the condition of the 
gravid uterus. Of these, the most common are scarlatiniform erythema, 
impetigo herpetiformis, dermatitis herpetiformis, and verrucse of the 
vulvar region. 

Auto -infection. — This is a field of investigation the confines of 
which have been barely touched by the explorations of modern science. 
At present it is demonstrable merely that the alimentary tract is trav- 
ersed by innumerable micro-organisms which are wholly innocuous. 
Under certain favoring conditions, however, these germs may either be 
commingled with others introduced from without, and thus become in 
various degrees dangerous to the economy from slight perversion of 
health to actual destruction of life in a relatively brief period of 
time ; or the innocuous parasites with and without the cooperation of 
the toxins they engender may suddenly become inimical to health from 
a change in their condition. 

Ingesta. — Food and medicines are responsible for many cutaneous 
lesions in consequence, first, either of an inherent toxic quality in the 
substance ingested ; or, secondly, in consequence of a special irritability 
of the alimentary canal existing at the time of such ingestion, the 
cause of the disorder being at other times ineffective. 

Among the foods capable of producing urticarial distress may be 
named shell-fish, the smaller berries having seeds, cheese, pickles, 
oatmeal, buckwheat, mushrooms, olives, the skins and seeds of grapes 
and of oranges, and certain kinds of fish, as well as alcoholic bever- 
ages. A large list of medicinal substances is enumerated in the chap- 
ter on Dermatitis Medicamentosa which are capable of producing skin- 
eruptions. Among these may be named, as illustrative of the group, 
the salts of bromine and of iodine, arsenic, quinine, copaiba, belladonna, 
and a number of the new remedies produced by the action of glacial 
acetic acid upon the petroleum-products, such as antifebrin and phe- 
nacetine. 

The Physiological Crises are not in themselves primary causes 
of dermatoses, seeing that the larger number of all members of the 
human family survive them without harm to the skin. It is none 
the less true that they furnish influences which modify and at times 
invite exanthemata. The possibilities of the pregnant state in con- 
nection with cutaneous disease have already been explained. Denti- 
tion is a period in which the child is often tormented by an eczema 
displayed in greatest profusion over the cheeks; and the puberal 
epoch of both sexes is one in which are manifested many of the dis- 
orders related to the repression, perversion, or excessive indulgence 
of the sexual function. Many of the chloasmata are conspicuous in 
women at the time of the menopause ; and this also is a period in which 
may be recognized irregularities in the performance of the sweat-func- 
tion as well as in the subjective sensations experienced in the skin. 



6Q GENERAL ETIOLOGY. 



EXTERNAL CAUSES. 

Innumerable agencies operate from without capable of exciting or 
aggravating cutaneous affections : in fact, it may be set down that few 
if any of the forces operating externally upon the skin from the begin- 
ning to the end of life may not exert an unfavorable effect upon it if 
their operation be excessive, untimely, or associated with other exter- 
nally operating factors. Briefly, some of these agencies operate singly ; 
others in cooperation ; some operate with grave, others with trifling 
effect ; some invariably, others but rarely, induce a deleterious effect 
upon the skin ; some, though exerting an influence wholly external to 
the skin-surface, cooperate with internal agencies. In the latter class 
may be named the hand of the syphilitic subject, which may exhibit 
syphilodermata largely due to the influence of the articles handled 
in the trade or occupation of the subject of the disease. 

Scratching" is a fruitful source of cutaneous trouble either when 
operating to originate or to aggravate an exanthem. Its symptoms are 
carefully studied by all diagnosticians, as they betray evidences of 
itching, which the efforts at scratching are exerted to alleviate. 
The regions most affected when scratching is severe (as in prurigo, 
scabies, pediculosis, and the forms of pruritus dependent upon visceral 
disease, such as glycosuria, tuberculosis of the adrenals, etc.) are, as a 
rule, those most readily reached by the hands either of an infant or 
an adult. In these parts may then be recognized the excoriations, fre- 
quently in two, three, or four parallel or approximated lines, blood- 
specks, pustules, papules, thickening, and even extreme induration and 
pigmentation of the skin, due solely to the traumatisms of the surface 
of the integument. 

Solar Light and Heat, and Thermal Changes (whether due to 
solar or artificial influence, as well as cold), are frequent and efficient 
sources of damage to the skin from the slightest grade of inflam- 
mation to the severest destruction. To solar light is to be attrib- 
uted the production of freckles, tan, and other pigmentations of the 
surface ; to heat are to be attributed the erythema, the eczema, and 
the various grades of dermatitis which may follow exposure to the di- 
rect rays of the sun. Other temperature-effects, including those pro- 
duced by extremes of both heat and cold, are to be classed in the same 
category. Exposure of the skin to a temperature of over 100° F. pro- 
duces merely a transient erythema, which under a further elevation of 
sixty-five degrees will not subside for several days. At a temperature 
of 212° F. all grades of acute dermatitis are awakened, with the pro- 
duction of bullae, up to the point at which complete destruction of the 
integument occurs. 

The Influence of the Seasons is of the same general character. 
Some cutaneous diseases are worse in summer ; others in winter. 
Prickly heat (lichen tropicus) is peculiar to certain warm seasons ; 
frostbite, with its subsequent hyperemia, exudation, or gangrene, occurs 
in winter ; pruritus is common in cold weather ; erythema multiforme 
is most frequent in the autumn and in the spring. 

Exposure of the Naked Skin to the X-rays in securing skiagraphs 






EXTERNAL CAUSES. 67 



and similar records, the serious effects of which have been noted, are 
probably due less to burning than to the actual transmission of exceed- 
ingly minute metallic particles carried not merely to the skin itself, but 
to the subcutaneous tissues, and even to the deepest structures examined 
by the aid of the ray. As a result, not merely severe and persistent 
inflammation and ulcerations of the entire skin have been produced, 
but changes have been wrought in the bones and periosteum. 

Climate has a determining influence upon many cutaneous disorders, 
and this of a sort which it is difficult to assign either to internal or 
external influence. The effects of climate are exceedingly complex, and 
probably include the agencies which favorably or unfavorably affect 
the health in the direction of atmospheric humidity or dryness ; abun- 
dance or scarcity of sunlight; the prevalence of favoring' or injurious 
winds and storms ; a salubrious or insalubrious food- and water-supply ; 
the average temperature of the earth's surface by day and by night ; 
the presence or absence of sources of malarial plasmodia ; and proxim- 
ity to the sea, to mountain regions, or to extensive growths of pine 
forests. Thus leprosy, Lombardy erysipelas (pellagra), biskra bouton, 
ainhum, and other affections, though not seen exclusively in one coun- 
try, are for the most part prevalent in countries Avhich may well be 
I contrasted with others where such affections are regarded as curiosities. 
• Mycetoma, for example, has been studied for the most part in India, 
while less than half a dozen cases of that disorder have been recognized 
in the North American continent. 

Occupation. — An enormous number of dermatoses are due exclu- 
j sively to the occupations of men and women. In France, where such 
I occupations are highly specialized on account of the artistic and skilled 
work of the people in numerous lines, these disorders are known as 
the " professional dermatoses," and the diagnostician there is often en- 
abled to decide the character of the work performed by the laborer on 
inspection of his hands. The workers in dyes, in chemicals, and in 
drugs suffer in one way ; the men who handle tiles, bricks, mortar, 
or clay in another ; the baker, the confectioner, the cook, the laundress, 
the green-grocer, the seamstress, the shoemaker, the carpenter, and the 
machinist have each their forms of erythema, dermatitis, keratosis, 
or induration. Similarly those whose faces are much exposed, as the 
wheelmen of vessels, tram car-drivers, locomotive-engineers, and day- 
! laborers, exhibit symptoms in that region. Butchers, w r ool-workers, 
' cattle-men, and sheep-shearers are liable to contract glanders, ring- 
worm, or malignant pustule. They avIio handle the bodies of the dead 
are prone to tuberculosis of the hands (anatomical tubercle), and those 
compelled to stand much of the time are exposed to the consequences 
] of varicose veins of the legs and resulting eczema of that region. 

Clothing'. — The coarse clothing worn by the poorer classes is often 
a source of skin-mischief, particularly when employed for infants ; and 
persons of both sexes and all ages exhibit marked results from the 
i wearing of flannel next the skin. Often the influence of clothing is 
I commingled with that of dyes, as when brightly tinted flannel colored 
with anilin produces a dermatitis of high grade with distinct staining 
of the skin over which such clothing has been worn. In the same list 



68 GENERAL ETIOLOGY. 

must be included the effects produced by ill-fitting shoes, corsets, 
trusses, napkins, " pads," supporters, crutches, orthopaedic apparatus, 
hat-bands, stockings, garters, and chest-protectors. Here, too, more 
than one cause may be efficient in the production of disease, as when 
clothing becomes a nidus for parasites, or is worn next the skin when 
soiled with abnormal or even physiological secretions. 

Chemical, Medicinal, and Mechanical Irritation may be respon- 
sible for many affections of the integument. Of articles effective in the 
first category, may -be named the stronger acids and alkalies ; of those 
in the second class, arnica, cro ton-oil, mustard, Mucund pruriens; of 
those in the last class may be suggested all substances capable of ex- 
erting undue friction upon the surface, such as pumice-stone, combs, 
brushes, towels, and the articles employed in the operations of the 
manicure. 

Filth is a potent factor in both the production and the aggravation 
of skin-diseases, its effects being decidedly most apparent in patients 
applying to the public dispensaries. In infants the skin unwashed 
even for a fortnight usually becomes the seat of an irritating urticaria. 

Traumatism plays a most important part in cutaneous etiology. It 
includes the action, in scratching, of the nails, the knees, heels, elbows, 
etc., as well as the influence of several articles used for the same pur- 
pose — pieces of cloth of various kinds, etc. In this way excoriations, 
and even infiltrations, of the skin are induced. Under the head of 
traumatisms should be considered also injuries of the skin-surface pro- 
duced by animals, occasionally with the added effect of a toxicant. 
Here are included the wounds produced by lice, fleas, bugs, and acari ; 
the bites of serpents, horses, dogs, and cats ; and the accidents produc- 
ing traumatism of every kind, not omitting the intentional wounds in- 
flicted by the surgeon and their results. 

Transmission by Contagion, by Infection, and by Parasites. — 
Some disorders with cutaneous phenomena are transmissible from dis- 
eased to healthy persons through the medium of the atmosphere, and 
are termed infectious; others are termed contagious when transmis- 
sible solely by contact. Some maladies, such as variola, scarlatina, and 
measles, are conveyed by both methods, and hence belong to the cate- 
gory of both contagious and infectious disorders. Yet others are 
transmissible only through infection with a specific virus ; such dis- 
eases are syphilis and lepra. By many writers the terms infectious 
and contagious are used as synonyms. 

Parasitic Diseases. — Under this title were once included solely the 
dermatoses induced by the presence of the animal and vegetable para- 
sites. Among the former may be named scabies and pediculosis ; 
among the latter, ringworm of the scalp and of the beard. But the 
term parasite has acquired a much wider scope since the recognition of 
the micro-organisms which have been demonstrated to be efficient in 
the production of a long list of cutaneous affections. Among these may 
be named the bacilli productive of cutaneous tuberculosis and of 
lepra ; the pus-cocci, responsible for the several forms of impetigo and 
pustular eczema ; and the streptococci, recognized in several forms of 
dermatitis. In most of the dermatoses which are recorded to-day as 



EXTERNAL CAUSES. 69 

parasitic, germs have been recognized, which either singly or in coop- 
eration with others have been proved to be effective in the production 
of these disorders, or have been demonstrated to play an active part 
in either their extension or exacerbation. 

The popular ideas respecting the frequency and danger of contagion 
in diseases of the skin are often erroneous. The non-parasitic affec- 
tions are, and probably always will be, more numerous than all others. 
The danger of communicating scabies, syphilis, and other affections by 
handshaking is not as great as is generally believed. On the other 
hand, the dangers which by the mass of people are little considered 
are often the graver and more to be avoided. Among these may be 
named the use in public of the roller-towel, the drinking in common 
from public cups and glasses, promiscuous kissing, contact with the 
lower animals exhibiting diseases of the hide, of fur, or of feathers, the 
wearing of a stocking on one foot which the day before was worn over 
the surface of a fellow-member the seat of disease, and the wearing of 
velvet- or fur-trimmed collars on top-coats after the occurrence of a 
disease of the skin of that part of the neck with which the garment is 
naturally brought into contact. 



IV. GENERAL PATHOLOGY. 



The pathological processes and changes in the skin correspond in 
general to those occurring in other organs of the body, but they are 
modified by the peculiar and complex structure of the integument and 
by its exposure to many and varied external influences. Frequently 
the skin is but one of several organs involved in a common process, as 
in malnutrition, syphilis, or leprosy. More commonly the pathological 
changes in the skin which are largely or entirely dependent upon general 
conditions are not accompanied by similar alterations of other organs. 
In this category belong the toxic erythemas, some eczemas, and many 
other dermatoses. In a large number of disorders of the skin no dis- 
turbance of the general economy can be discovered. The relation of 
cutaneous disease to toxaemias, to vasomotor, nervous, trophic, and 
other constitutional disturbances, and also to micro-organisms and 
other local influences is discussed in the chapter on General Etiology. 
Many of the pathological processes involving the skin are but imper- 
fectly understood, and are difficult to study because of their constant 
modification by external influences ; but the pathological anatomy ex- 
plaining these processes has been extensively investigated, and offers a 
favorable field for further research, since the freely exposed surface 
renders it easy to remove tissue for study at any desired stage of the 
process. 

The vascular portion of the skin is the corium, in which inflamma- 
tory, hypertrophic, atrophic, and other changes, including new-growths, 
correspond more or less closely with similar changes in other organs of 
the body. Special features are found in the involvement of the coil- 
glands and sebaceous glands, and of the hair-follicles. The large 
amount of elastic tissue and the degeneration to which it is subject 
may greatly modify the histological appearances of a section under 
examination. 

It is chiefly the epidermis, however, with its peculiar structure and 
its independence genetically of the corium that gives to cutaneous path- 
ology its chief characteristics and presents its most difficult problems. 
The rete is the most important layer, and participates in all inflamma- 
tory and in most other diseases of the skin. It is subject to intercel- 
lular and cellular oedema, to several forms of cell-degeneration, to hy- 
pertrophy and to atrophy, and is specially active in all epithelial new- 
growths. In its deeper layers of cells occur the various modifications 
of the true pigment of the skin. In a large class of cutaneous dis- 
orders, characterized by an excessive or abnormal cornification (hyper- 
keratosis and parakeratosis) of the upper rete-cells in the formation 
70 



GENERAL PATHOLOGY. 71 

of the horny layer, the most manifest changes are in the granular and 
the horny strata. 

The inflammatory diseases of the skin have been supposed to begin 
in the corium, the epidermis being secondarily involved. It is prob- 
able, however, that in many instances the vascular disturbances are 
preceded by changes in the terminal nerve-filaments and adjacent cells 
of the rete. 



V. GENERAL DIAGNOSIS. 



The establishment of an accurate diagnosis in cutaneous diseases is 
essential to their successful management. This statement is rendered 
necessary in this connection by the prevalence of a belief among the 
uneducated that the disorders of the skin, exhibited for the most part 
in visible symptoms, can safely be treated on general principles with- 
out a recognition of the nature of the malady. By many practitioners 
the demand for an accurate diagnosis is ignored in consequence of a 
too general impression that the desired end is to be pursued through 
great and perplexing obscurity. Yet with patience, method, a habit 
of careful observation (without which no physician is successful), and 
a reasonable degree of skill both practitioner and student can, in the 
large proportion of all cases, attain their purpose. 

It is a popular error that the sole requisite for establishing a diag- 
nosis is the exhibition of an affected portion of the integument to the 
eye of him who is consulted with a view to its relief. The physician 
is supposed to inspect this surface attentively for a few moments, and 
then to pronounce definitely upon the nature of the disease present 
and the therapeutic measures to be adopted. While such a procedure 
is possible to the expert in a limited number of cutaneous disorders, in 
a large number of cases far more than this is requisite, and, indeed, 
is fully as essential here as in the investigation of disease involving 
any other organ of the body. 

It is true that erythema, urticaria, dermatitis, eczema, purpura, 
alopecia, and many other affections of the skin may often be recognized 
after simple and brief inspection of the region involved ; but the cause 
of such disorders and their relation to the general health of the patient, 
all of which knowledge is essential to their proper treatment, can only 
be obtained after a much more thorough examination. As a rule, it is 
desirable, first, to secure a history of the physical and mental condition 
of the patient in the past ; then should follow the special history of the 
disorders of the skin; lastly, an examination of the patient and of the 
affected integument. The family history may be of value in making a 
diagnosis. For the purpose of methodically arriving at these facts, 
and of preserving them for future reference, they should systematically 
be recorded. The following are some of the points upon which it will 
generally be found useful to secure information : 

The name, residence, age, sex, occupation, and married or unmarried 
state of the patient should be known, as also, whenever practicable, 
the health-history of parents and children. In the case of women it 
is not only necessary to learn the history of the menstrual function in 
the past, but it is of the highest importance to be informed also as to 
72 



GENERAL DIAGNOSIS. 73 

the previous occurrence of abortions and miscarriages, and, if such 
have occurred, the order observed by these with relation to the birth 
of viable infants. The significance and value of several of these facts 
have been described in the chapter on Etiology. With respect to the 
history of the products of conception, it should never be forgotten 
that it has a most important bearing upon the question of syphilitic 
infection. The absolute exclusion of syphilis in any obscure case is a 
long step in the direction of an accurate diagnosis. In the instance 
of male patients, questions will usually elicit either admission or denial 
of the fact of a precedent or present venereal disease, and the answers 
should be regarded as valueless or trustworthy according as they are 
or are not substantiated by corroborative clinical facts. 

Then should follow some record of the habits of the patient, as to 
active or sedentary employment, bathing, food, and drink, including 
under the latter term the use of beer, wine, and spirits. The history 
of any previous disorders, whether of the skin or other organs, should 
be satisfactorily clear, and the dates of occurrence, recurrence, and con- 
valescence be at least approximately discovered. The patient should 
also make known whether he has had refreshing sleep ; whether he has 
undergone mental anxieties (domestic, financial, etc.) ; whether he has 
suffered in his digestive, respiratory, circulatory, genito-urinary, or 
nervous system. Defects in elimination, assimilation, and nutrition 
should be noted ; and when the symptoms suggest disease of other 
organs than the skin the patient should be subjected to the proper 
physical examination. 

This much ascertained, the patient should be encouraged to narrate 
as succinctly as possible, and as far as may be in his own terms, the 
history of the present cutaneous disorder. A systematic series of 
questions put by the examiner should disclose, if possible : the cause 
of the disorder ; its appearance when first seen, and any changes in 
character and type which have since occurred ; the regions of the 
body affected, in order of involvement ; the method of extension, by 
peripheral enlargement of the early areas, or by the appearance of new 
lesions at a distance from the first ones ; the rapidity and regularity of 
the progress of the disease and its duration ; the subjective sensations ; 
and the influence of seasons and temperature upon the disorder. The 
treatment to which the disease has been subjected should then be de- 
tailed, this frequently furnishing a key to the diagnosis and therapy 
of the malady. In an incredibly large proportion of all cases ignor- 
antly directed and vicious internal or external medication has either 
begotten or aggravated the disease of the skin. This much ascertained, 
the physician is ready to examine the affected surface for himself. 

During, however, the verbal interrogations which are required for 
this part of the exploration of the case, the watchful and observant 
practitioner will probably have secured for himself some useful infor- 
mation of which the patient is totally unconscious. Much of this is 
difficult to describe, as it is the rich fruit of wide experience and care- 
ful scrutiny. With a gentle, courteous, and sympathizing manner the 
diagnostician must combine the art of a detective and the skill of a 
swordsman. Glancing occasionally at the face of his patient while 



74 GENERAL DIAGNOSIS. 

making record of the answers given, he will, of course, have observed 
any eruption upon that portion of the body. He will have made a 
mental note of the temperament of the sufferer, and of any movement 
made by the latter indicating a tendency to scratch or rub portions 
of the skin. He will have noticed the posture, clothing, and head- 
apparel ; the existence of hair on the scalp or extensive baldness ; 
the condition of the exposed hands as indicating manual labor or the 
reverse ; and, in the absence of facial lesions, will have observed the 
special tint of the skin of the face, as suggesting ansemia, chlorosis, or 
a general condition of cachexia. The facial expression, .as indicative 
of anxiety or placidity, habits of debauch, sexual excesses, etc., will not 
have escaped his attention. All this and much more will possibly have 
enabled the questioner to direct his interrogatories into the channel in 
which they will elicit the most useful responses. The posture, cries, 
facial expression, and general condition of nutrition of the infant will 
have been no less carefully noted. 

Proceeding to the examination of the affected integument, the phy- 
sician must assure himself of a good light, as colors are best distin- 
guished by daylight and artificial illumination should be reserved for 
exploration of the cavities of the body. The air of the apartment 
should be sufficiently warm to permit of exposure of the person with- 
out discomfort and without causing disturbance of the cutaneous cir- 
culation. Adult males and children of both sexes should have the 
clothing completely removed so that all portions of the skin may be 
inspected. One portion of the body may, however, be examined, and 
then covered if desired, while the examiner proceeds to direct his 
attention to another part. In the case of women the investigations 
should be conducted with all the tact and delicacy to which the sex is 
entitled. 

The examination, whenever practicable, should extend over the entire 
surface of the integument. The importance of this point can scarcely 
be exaggerated. It must be remembered that the physician should be 
very much wiser than his patient, and the assurances of the latter are 
always to be accepted with reserve. Thus, one who merely exposes his 
leg, stating that this is the only part of his body affected, may have 
concealed beneath his clothing extensive varicosities of the veins of 
the thigh, a typical syphilitic exanthem over the belly, a significant 
scar on the elbow, an extensive patch of tinea versicolor on the surface 
of the chest, or a blennorrhagic discharge from the urethra, the medi- 
cation of which has induced the rash for which he seeks relief. These 
are not the rare, but are the common cases of a daily experience. 

Observation should be had at this time of the general and special 
features of the eruption. As to the former, the following considera- 
tions should be borne in mind : 

The original manifestations of a cutaneous disease may be masked 
or entirely hidden by the lesions resulting from scratching, or by a 
dermatitis due to local applications, or to drugs swallowed for the 
relief of the original disorder. It is of the greatest importance that 
the accidental nature of these symptoms be recognized, as they other- 
wise lead to great confusion in diagnosis. 



GENERAL DIAGNOSIS. 75 

A very few diseases may involve the entire surface of the body, 
leaving no part unaffected, and are then called universal ; more fre- 
quently an eruption aifects at one time several or most of the regions 
of the body-surface, and is then called generalized ; much more com- 
monly an eruption aifects a considerable portion of but one or several 
* regions, and is said to be diffuse ; or it is limited to small areas of one 
or several definite regions, and is known as a local eruption. 

A symmetrical eruption, one equally distributed over corresponding 
regions of the two lateral halves of the body, is rarely the result of an 
etiological factor operating upon the outer skin. It more often points 
to an efficient cause of so-called " internal " origin, one influencing the 
inner skin or the internal organs. An eruption affecting the covered 
integument, never creeping out upon the exposed surfaces, suggests the 
operation of the clothing, as the latter may chance to prove the nidus 
or protector of a parasite, the fabric which has been colored by a noxi- 
ous dye, the recipient of a chemically altered secretion which has proved 
irritating to the surface, the instrument of friction, or the source of 
increased temperature at the surface by its non-conductivity of heat 
and unseasonable thickness. An eruption accompanied by excoriations 
and scratch-lines is usually severest in the parts most accessible to the 
hands, and least developed where the latter have the least play, as 
over some parts of the back. An eruption limited to the hands is 
likely to be one induced by an agent to which the hands alone have 
been exposed. Such are the eruptions originating in the trades and 
domestic occupations ; in the latter, an eruption more distinct on the 
right hand, and especially about the right thumb and index finger, tells 
its own story when the hand-worker is not ambidextrous nor left- 
handed. Artificially and intentionally produced eruptions, as in ma- 
lingering, hysteria, mental depravity, and insanity, usually occur also 
in parts to which the right hand finds easy access. 

Eruptions occurring on the face, the hands, and the genitalia of 
men, or on the face, hands, and mammae of women, point to external 
contact or contagion (poison-ivy, scabies, croton-oil, etc.), since, next 
to the face, the hands are more commonly brought in contact with the 
parts named in the sexes respectively, as the wearing-apparel of each 
suggests. 

An eruption limited to the forehead suggests an inspection of the 
hat-band, the veil, or the overlying false hair ; to the ears of women, 
a glimpse at possibly cheap ear-rings ; to the centre of the root of the 
neck, before or behind, a scrutiny of the collar-button and collar ; to 
the anus of the baby, an inquiry as to the changing of its napkins ; 
to the wrists of the adult, a question as to the cuffs worn ; to the feet, 
information respecting gaiters, varicose veins, recently cut corns, and 
ill-fitting boots. Eruptions springing from each of these causes have 
long and vainly been treated as " diseases of the blood." 

Eruptions markedly asymmetrical are indicative of asymmetrically 
operating causes — that is, the accidents of environment, or else influ- 
ences exerted within the body unequally on its two lateral halves, 
Thus, an orthopaedic apparatus worn to correct talipes excites a der- 
matitis of the leg of the affected side only ; and zoster of the trunk is 



76 GENERAL DIAGNOSIS. 

evident on that side supplied by the intercostal nerve which has been 
inflamed. The greater stress may be laid on this peculiarity, as the 
law of symmetry, in eruptions not occasioned by causes operating on 
the outer skin, is faithfully observed in nature. The earlier syphilides, 
the quinine-exantheni, rubeola, and even lupus erythematosus, are re- i 
markable illustrations of this fact. 

Proceeding with the visible characteristics of the disorder, the phy- 
sician will not fail to note an acuteness or chronicity of the eruption ; 
also, the presence or absence of an exudate on the surface. 

After obtaining an impression of the general features of an eruption 
the individual lesions should be carefully studied. The type of lesion 
(papule, tubercle, vesicle, etc.) should be noted. When the lesions are 
multiform the different types should be examined to determine, if pos- 
sible, which are primary and which secondary in appearance, which are 
essential and which accidental in the process. For the purpose of 
studying the characteristics of the individual lesions, those of most 
recent appearance (usually at the border of a patch), and as yet un- 
modified by scratching, treatment, and other influences, should be 
selected. Often, however, the full evolution of a lesion requires time, 
and its successive stages should be determined by observing a number 
of lesions of different ages. 

The arrangement of lesions varies greatly in different diseases. 
When grouped such lesions may develop in circular, oval, angular, or 
irregular-shaped areas ; or in circinate, gyrate, serpiginous, straight, or 
irregular bands and lines. In some affections (as ringworm, psoriasis, 
syphilis) the areas may clear in the centre as the border progresses. 
Lesions may be grouped, and yet discrete in that each lesion preserves 
its outline and identity ; or they may coalesce so completely that all 
trace of the form of the individual lesion is lost. 

The definition of lesions is another important diagnostic feature in 
which cutaneous affections vary greatly : the line dividing the diseased 
from the normal skin may be so sharp and fine that it can be traced 
with the point of a pin ; or the lesion may shade so gradually into the 
normal skin that its outline cannot be definitely determined, and it is 
said to have poor definition or none. 

The color of lesions of the skin often depends greatly upon circum- 
stances having no bearing upon the disease in question. It thus varies 
with the natural color (light or dark) of the individual's skin, with the 
temperature of the surface, and with the amount of irritation to which 
the surface has been subjected by friction of rough clothing, scratching, 
treatment, etc. There are, however, some diseases (syphilis, lichen 
planus, tinea versicolor, favus, and others) in which the color may be 
of great importance in the diagnosis, and there are many maladies in 
which consideration of this characteristic of the eruption is of value 
if the accidental modifications be borne in mind. The acuteness or 
chronicity of a disease is often indicated by the color of the lesions. 
The persistence, modification, or disappearance of color under pressure 
should be noted. For this purpose a small glass disc or glass tongue- 
depressor is better than the finger. 

In judging of the size of a lesion it is sometimes important to learn, 



GENERAL DIAGNOSIS. 77 

by palpation, how much of it is above the general surface of the skin 
and how much is more deeply situated. In noting the shape of papules, 
tubercles, vesicles, and pustules, both apex and base should be taken 
into consideration. Thus, the apex may be pointed (acuminate), rounded 
(obtuse), flat (plane), or depressed (umbilicated). The base may be 
round, oval, angular, polygonal, or irregular. 

The situation of lesions in or about the hair-follicles or at the 
opening of the ducts of the sebaceous or coil-glands is a diagnostic 
point of great value. It is important to know if certain lesions 
appeared first on normal skin, or if they originated in other lesions. 
Thus, vesicles and pustules may arise from sound surfaces, or from the 
apices of papules or tubercles. The majority of even the elementary 
lesions are probably preceded by macules, which, however, are usually 
so transitory as to be unrecognized and unimportant. 

The career of an individual lesion, which often bears no relation to 
the duration of the disease as a whole, should be noted. Thus, the 
vesicle of eczema rarely exists as such for more than a few hours, 
though by the formation of new vesicles eczema may persist for months, 
while in zoster individual vesicles last several days, though the disease 
as a whole is short-lived. In some diseases the type of lesion remains 
the same throughout its career unless modified by treatment or external 
influences, while in others the type changes or is complicated by other 
types. Thus, the papule may be modified by developing at its apex a 
vesicle or pustule. The career of lesions can usually be studied, not 
only by watching them from day to day, but also — and more easily — 
by observing at one time a number of lesions in various stages of 
development. 

As the lesions of different affections vary greatly in their evolution 
and career, so do they in their involution. While in the majority of 
instances it is the recent and newly formed lesion that is most desira- 
ble for purposes of study, there is often much to be learned from the 
manner in which lesions disappear and in the traces they leave behind. 
The papule or tubercle which ulcerates usually suggests (aside from 
some rare diseases) syphilis, tuberculosis, or carcinoma, and may be 
sufficient to exclude from the diagnosis the possibility of psoriasis, 
seborrhoea, and other superficial affections. In a doubtful case the 
termination of some of the lesions in scar-tissue may be the one fact 
needed to make a differential diagnosis between seborrhoea and lupus 
erythematosus, or between a circinate form of psoriasis and a similar 
type of syphilitic eruption. Pigmentation sufficiently characteristic 
for a diagnosis is left after the otherwise complete involution of some 
lesions. This is most frequently true in zoster, lichen planus, and 
some forms of syphilitic eruptions. In estimating the time of involu- 
tion of lesions and in making a prognosis regarding the disappearance 
of pigmentation (a point upon which patients are often very solicitous) 
it should be remembered that pigment is usually removed very slowly 
from the lower extremities and other dependent portions of the body, 
and that in such localities it may persist for months or years after it 
has disappeared from parts in which the return-circulation is better. 

Certain lesions have special features that should be studied. These 



78 GENERAL DIAGNOSIS. 

are given in detail in the last division of the outline at the end of this 
chapter. 

Before concluding his examination the physician will rupture a 
bleb, pustule, or vesicle, should such be found, to discover the nature 
of its contents. He will remove one or several crusts in sight, to 
expose the surface on which they rest. He will scrape away a few 
scales with the dermal curette for a similar reason. He will pinch up 
between his thumb and finger a portion of each part, in order to deter- 
mine its infiltrated condition, its atrophy, or its attachment to the tissues 
beneath. He will pass his hands over the surface to recognize the firm- 
ness or the softness of the lesions, their inflammatory, hyperplastic, 
or neoplastic character, their dryness or moisture, and the existence of 
sebaceous or of perspiratory secretion. He will look at the mouths of 
the follicles where such secretion is retained or is abundantly exuded. 
He will discover any lice or their ova between or upon the hairs, any 
ascarides at play about the anus, any morbid formation of the nail or 
deformity of its matrix. He will examine for inguinal, post-cervical, 
axillary, and epitrochlear adenopathy, and will thus be often greatly 
aided in his task. This done, he will question in turn for himself, and 
by the methods recognized in medical science, the organs of the body 
other than the skin. He will inspect the tongue carefully, and if then 
he considers himself through with the mouth he will be guilty of 
great error. The gums rarely deceive the questioning eye; the inside 
of the lips, the fauces, and the tonsils are all to be searched. A 
mucous patch here will often echo the story of a palmar or a plantar 
sphiloderm. The laryngoscope may be called for in syphilis, cancer, 
lupus, and leprosy. The degree of distention of the belly and the 
region of hepatic dulness should not be overlooked. The genitalia of 
men, and of children and infants, can usually be explored. For 
women unaffected with syphilis or disease limited to these parts an 
exception in this particular should usually be made. 

In many cases the microscopical and bacteriological examination 
of hairs, scales, crusts, exudate, or tissue will aid greatly in the diag- 
nosis, and should not be neglected. In some instances such examina- 
tions are essential to the formation of a correct diagnosis. 

With the necessary reserve of all very obscure cases, it may be said 
that the physician who has conscientiously conducted an examination 
after the manner described above is in possession of the diagnosis for 
which he seeks. If the facts thus acquired have properly been re- 
corded, and yet do not spell out such a diagnosis to his eyes, they will 
probably be legible to others with a wider experience or riper judg- 
ment, to whom such a record mav be shown. It is not claimed that 
this exhaustive method of examination is requisite in every case, as, 
for example, in order to recognize a favus or to differentiate erysipelas 
from erythema. But it is certain that few obscure cases of skin dis- 
ease will remain such under severe scrutiny, and the establishment of 
a thorough and exhaustive method of examination is important in the 
earliest experience with disease. Let the student or the practitioner 
conduct such an examination in the first few cases of eruption upon 
the surface of the body for which his advice is sought, and he will 



GENERAL DIAGNOSIS. 



79 



establish a habit of observation in comparison with which his pecuniary 
or professional success in the management of the same cases will in- 
deed be of trivial worth. 

Upon one special point should the inexperienced physician be 
guarded. It relates to the acceptance of a diagnosis which is not 
based upon such an examination as that given in outline above. A 
diagnosis by a patient is usually faulty, and the verdict of even skilled 
practitioners may be founded upon an error. The careful diagnostician 
should begin his task in a spirit of skepticism, and pronounce definitely 
only upon ascertained facts. The man who says he has an " eczema " 
may be louse-bitten ; the woman who has been " overheated " may 
prove syphilitic. The patient recognized as suffering from ringworm 
of the beard may not have been iufected under the hands of a barber. 
Finally, the eruptions upon patients unmistakably syphilitic are often 
of other than syphilitic origin. These infected subjects — men, women, 
and children — are exposed daily to the accidents from which the non- 
infected suffer. They exhibit acne, physiological alopecia, and der- 
matitis medicamentosa equally with the non-syphi]itic. 

The following outline for the methodical examination of a patient 
affected with skin-disease is based on the subjects considered in the 
preceding pages, and is given in such detail that a careful investigation 
of the questions suggested should furnish material for all but excep- 
tional cases. For the average case much may be omitted. 

The first attempts to follow such a scheme are necessarily tedious, and 
therefore often discouraging; but one patient thus carefully examined 
is of greater educational value than an aimless and indefinite examina- 
tion of a dozen cases. There is no greater economy of time than is 
found in methodical and systematic habits of work. 



HISTORY. 



I. Name and Kesidence. 
II. Age. 

III. Sex. 

IV. Married or Unmarried. 

1. Children. 

a. Living. 

b. Dead. 

2. Abortions or Miscarriages. 

V. Family History. 
VI. Individual History, including that 
of previous skin-diseases. 
VII. Occupation. 
VIII. Habits, of eating, drinking, bathing, 
tobacco-usage, etc. 

IX. Present State of Health. 

(Note the condition of the digestive, re- 



spiratory, circulatory, genito-urinary, 
and nervous systems ; also, defects in 
assimilation, elimination, and nutri- 
tion.) 

X. History of Present Skin-dis- 
eases. 

1. Cause— if known. 

2. Character at first. 

3. Sites affected in order. 

4. Manner of progressing. 

a. Slow or rapid. 

b. Steady or irregular. 

c. With exacerbations and remis- 
sions. 

d. With periods of entire freedom 
from symptoms. 

5. Changes in character. 

6. Subjective sensations. 

7. Duration. 

8. Effect of temperature and seasons. 

9. Treatment to date. 



OBJECTIVE SYMPTOMS. 



B. 



Accidental Complications due to 
scratching, treatment, etc. 

Site. 

1. Universal. 

2. Generalized. 

3. Diffuse. 

4. Local. (Note influence of clothing, occu- 

pation, etc., 



C. Symmetry, or asymmetry. 

D. Acuteness, or chronicity. 

E. Moisture, or absence of. 

F. Individual Lesions. 

1. Elementary (macule, paprde, wheal, tuber- 

cle, tumor, vesicle, pustule, or bleb). 

2. Consecutive (scale, crust, excoriation, fis- 

sure, ulcer, or scar). 



80 



GENERAL DIAGNOSIS. 



I. Uniformity, or multiformity. 



II. Arrangement. 

1. Isolated 

2. Grouped. 

3. Discrete. 

4. Coalescing. 

5. Irregular. 



III. 



Definition. 

none.) 



(Sharp, fair, poor, or 



IV. Elevation, or depression. 

V. Color. 

1. Under pressure. 

VI. Shape. 

1. Apex. 

2. Base. 

VII. Size. 

1. Superficial. 

2. Deep. 

VIII. Anatomical site. 



IX. Consistence. 

1. Firm. 

2. Soft. 

X. Base. 

1. Color. 

2. Infiltration. 

XI. Evolution. 

1. From sound skin. 

2. From other lesions. 

XII. Career. 

1. Transitory. 

2. Persistent. 

3. Type. 

a. Simple. 

b. Changing, - 

c. Modified. 

XIII. Involution. 

1. Resorption. 

2. Exfoliation. 

3. Ulceration. 

4. Atrophy, etc. 

XIV. Sequelae. 

1. Stains. 

2. Scars. 



SPECIAL FEATURES TO BE OBSERVED IN CERTAIN LESIONS. 



A. Vesicles, Pustules, or Blebs. 

I. Koof. 

1. Tense. 

2. Flaccid. 

3. Easily ruptured. 

II. Contents. 

1. Translucent, or opaque. 

2. Serous. 

3. Purulent. 

4. Hemorrhagic. 

III. Surface beneath. 

IV. Areola. 

V. Involution. 

1. Desiccation. 

2. Rupture. 

3. Crusts. 

B. Scales. 

I. Size. 
II. Color. 

III. Quantity. 

IV. Consistence. 

1. Dry. 

2. Fatty. 

3. Friable. 

4. Tough. 

V. Attachment. 

1. Firm. 

2. Slight. 

VI. Surface beneath. 

1. Color. 

2. Dry. 

3. Greasy. 

4. Hemorrhagic. 

C. Crusts. 

I. Size. 
II. Shape. 

III. Color. 

IV. Composition. 

1. Serum. 

2. Pus. 

3. Blood. 

V. Attachment. 

VI. Thickness. 



VII. Consistence. 
VIII. Surface beneath. 

D. Excoriations. 
I. Distribution. 

U. Shape. 

III. Arrangement. 

IV. Kelation to other lesions. 
V. Exudation. 

E. Fissures. 

I. Distribution. 

II. Size. 

1. Length. 

2. Depth. 

III. Pain. 

IV. Moisture. 

F. Ulcers. 

I. Size. 
II. Shape. 

III. Depth. 

IV. Base. 

1. Soft. 

2. Infiltrated. 

3. Indurated. 

V. Edges. 

1. Sloping. 

2. Perpendicular. 

3. Punched. 

4. Ragged. 

5. Everted. 

6. Undermined. 

7. Soft. 

8. Indurated. 

VI. Floor. 

1. Smooth. 

2. Uneven. 

3. Clean. 

4. Pus-covered. 

5. Granular. 

6. Sloughing. 

7. Hemorrhagic. 

8. Glazed, 



GENERAL DIAGNOSIS. 



81 



VII. Secretion. 

1. Scanty. 

2. Profuse. 

3. Serous. 

4. Purulent. 

5. Hemorrhagic. 

6. Odor. 

VIII. Pain. 
IX. Crust. 
X. Evolution. 
XI. Duration. 

XII. Involution. 

{Note carefully the number and location 
of ulcers, the age of the patient, and the 
character of scars if present.) 

G. Scars. 

I. Size. 



II. Shape. 

III. Color. 

IV. Depression, or elevation. 

V. Texture. 

1. Soft, pliable. 

2. Hard, indurated. 

3. Thin. 

4. Thick. 

5. Smooth. 

6. Rough, corded. 

VI. Attachment. 
VII. Deformity. 
VIII. Subjective sensation. 

IX. Absence or presence of hairs, glands, 
and papillae. 



VI. GENERAL PROGNOSIS. 



The prognosis of most diseases of the human body is formulated 
with a view to the decision of the serious question of life or death. 
Occasionally this question arises in connection with skin-diseases. 
Many of the latter are trivial, some are grave, a few are inevitably 
fatal in their termination. Thus, general exfoliative dermatitis, lep- 
rosy, sarcoma, carcinoma, at times lichen ruber, and variola in the 
unprotected are of grave portent ; while the ordinary congestions and 
exudations, the great majority of all cases of acquired syphilis in 
adults, and the entirely curable diseases induced by parasites do not 
excite alarm in the breast of the average patient with respect to his 
longevity. 

The questions, however, as to his future, Avhich are urgently pressed 
by the victim of cutaneous disease, are both numerous and important. 
He is anxious as to the time during which he must suffer ; as to the 
possibility of conveying the disease to his progeny or other members 
of his family ; as to the disfigurement of his person that may result ; 
as to the scars which he may carry for the remainder of his life ; as 
to the possible recurrences of his malady in the future. The responses 
to these questions will largely be influenced by the prognosis of the 
physician. 

Some diseases of the skin are acute, pursue a rapid course, and 
are prompt to disappear. Others are chronic, rebellious to treat- 
ment of the most energetic and skilful character. Others, again, 
though not shortening life, are never relieved while life is continued. 
Some disappear only to reappear at more or less regular intervals. 
There are cutaneous diseases which affect one individual but once in 
his lifetime ; others which reappear at the instant the patient is again 
exposed to their exciting cause. There are cutaneous diseases so dis- 
torting and destructive in their effects that their victims have com- 
mitted suicide under the influence of the morbid emotions which they 
have as a consequence experienced. 

• The mental distress occasioned by even an insignificant cutaneous 
disorder is often out of all proportion to its exciting cause, and this 
should always be regarded in establishing a prognosis. The sexual 
hypochondriac has been made insane by an acne ; and the man or 
woman affected with syphilis has been made wretched for years by a 
recurrent erythema. 

Again, a disease of the skin may coexist with grave lesions of in- 
ternal organs, and the prognosis of the disease of the one be greatly 
influenced by that demanded by the other ; thus, there is occasional 
coexistence of syphilis and phthisis. Pruritus may be associated with 

82 



GENERAL PROGNOSIS. 83 

albuminuria ; and the eczema of an infant starving for want of breast- 
milk may hasten its marasmus to a fatal termination. 

Upon the answers given to his patient inquiring as to the prognosis 
of the disease of the latter will largely depend the professional success 
of the physician. Scrupulous honesty should here be welded with all 
the skill that science can command. That a disease does not endanger 
life is not an argument in favor of its amenability to treatment. The 
practitioner should never suffer himself to be pushed by his patient to 
the position that an obstinate disease is readily manageable. It is the 
height of folly to estimate lightly that zoster of the forehead, the scars 
of which the patient may exhibit to all who afterward look upon his 
face both in life and in death. He who engages to relieve an alopecia 
areata in the month may have a year in which to repent his precipi- 
tancy. There is no way in which the conscientious physician can so 
readily secure the confidence of his patient, and with it that will- 
ingness to submit to appropriate treatment which is begotten of such 
confidence, as by demonstrating his ability to forecast the future of a 
disease ; in other words, to describe accurately its prognosis. 



VII. GENERAL THERAPEUTICS. 



A consideration of the subject of the methods of treating skin- 
diseases in general suggests at once the intimate relation which subsists 
between the integument and other organs of the body. The etiology 
of one largely explains the causes of the disease in all. The patholog- 
ical processes in each are subordinated to the same general laws. The 
principles of treatment are very similar in all the disorders of the 
body. 

The object to be attained by treating a cutaneous disease is, first, 
its complete relief; secondly, where relief is impossible, such manage- 
ment of the morbid process as will mitigate its severity and render the 
victim of the disease more comfortable. A higher and more scientific 
achievement than either is the prophylaxis by which man is enabled to 
escape the disease altogether. He can by his wisdom largely diminish 
the danger to which his integument is exposed ; he can, to a certain 
extent, shelter himself from extremes of temperature, traumatism, toxic 
agents, and contagious diseases ; he can, by observing the simple rules 
of hygiene, fortify his skin against the lesser evils which may befall 
it. Here, however, the subject under consideration involves disease 
which is actually present and in progress. 

The management of diseases of the skin demands of the practitioner 
a sound knowledge of general medicine and an experience in disorders 
other than those of the integument. Dermatology is a branch of gen- 
eral medicine, and he who would succeed in the one department must at 
least be at home in the other. He who cannot succeed in the one 
field will almost surely fail to secure the best results in the other. 
Much indeed of the management of diseases of the skin can be cor- 
rectly described as the pure practice of medicine. Many of the 
methods, most of the means of diagnosis, much of the pharmaceutical 
aid utilized by the general practitioner, are indispensable in the field of 
dermatology. 

It is scarcely needful to set it down at this date that the old doctrines 
respecting both the danger of " driving in" certain diseases of the skin, 
and of the importance of "driving out" others, are relics of a super- 
stitious ignorance. There is no disease of the skin the continuance of 
which offers a bar to other disorders or furnishes a guarantee of the 
future health of the patient. There is no disease of the skin which 
does not call for relief as promptly as the requirements and safeguards 
of science will permit. The retrocession of the exanthematous symp- 
toms of a systemic poison are not of the class of involution of lesions 
to which attention is here directed. 

In beginning the treatment of disorders of the skin it is scarcely 

84 



GENERAL THERAPEUTICS. 85 

necessary to repeat that the diagnosis should be established by the 
methods already detailed ; and that in attempting to adjust remedies to 
the morbid state due attention must be given to the past history of the 
complaint, to its remote or immediate causes, to its duration, to the 
nature of the disease (whether the latter has changed in type or severity 
since the beginning), and in particular to the special features presented 
at the moment of instituting treatment. The matter of diet is one with 
respect to which experts are not as yet upon all points agreed. In 
general it may be said that in all inflammatory affections the diet 
should include food which is simple, digestible, and free from excess of 
nitrogenous and hydrocarbonaceous principles. The diet appropriate 
for the gouty state in the majority of gouty patients suffering from 
dermatoses must be rigidly enforced, even admitting that too severe a 
regimen is to be deprecated for the gouty when not actually suffering 
from a crisis of the disease. In all attacks of urticaria the food per- 
mitted should be made to correspond carefully with the list of articles 
known to be incapable of aggravating the disorder, and too much im- 
portance cannot be attributed to the regulation of the food of infants and 
children affected especially with eczema. In glycosuric xanthoma, in 
the pruritus of albuminuria, in the tuberculoses of the skin, in acne 
cachecticorum, and in other disorders the selection of a dietary appro- 
priate to the systemic state is of vital importance. On the other hand, 
it is to be conceded that in some cutaneous maladies, such as vitiligo, 
the disorders due to vegetable and animal parasites, in molluscum, and 
in other affections which might be named, the subject of dietetics is 
without importance. 

Like all other diseases of the body, those of the skin may be divided 
into three classes with relatively fixed limits. 

The first class embraces all the diseases which have a natural tendency 
to pursue their course to a favorable termination. It includes all those 
affections which, either mild or severe, require absolutely no treatment 
of an active character. It is the duty of the skilful physician to watch 
the evolution of these maladies, and to discharge a most important part 
by refraining from all therapeutic measures which in such cases might 
prove hurtful. By his judicious counsel, also, he hinders patients and 
their friends from pursuing a course which might prove prejudicial to 
the disease. 

The second class embraces all those skin-affections which are either 
inevitably fatal or hopelessly remediless while life is prolonged. For- 
tunately, this includes but a small proportion of the large list. Here 
the duty of the physician is plain. He should assuage pain, attempt to 
relieve deformity, administer to the comfort of the afflicted in other 
ways, and by his patient courage inspire confidence and hope. It 
must not be forgotten that the skill of man has not yet reached the 
acme of human need. In the presence of many diseases of the body 
he stands absolutely helpless, and the speediest w T ay to success in such 
cases is to begin by an honest admission of the plain fact. 

The third class of affections naturally embraces all not included in 
the first two classes. Here disease may be prolonged or be shortened 
in its course, rendered acute or chronic, made more or less endurable, 



86 GENERAL THERAPEUTICS. 

permitted to become inveterate, or absolutely be relieved by prompt 
and energetic measures, according as it is, or is not, judiciously and 
skilfully managed. Here are gained the most brilliant successes of 
the dermatologist ; here also occur his most humiliating failures. 

In the presence of a cutaneous disease which requires treatment the 
question naturally arises as to whether this treatment shall be internal — 
that is, by medicaments ingested ; or external — that is, by local thera- 
peusis ; or by combination of the two methods at the same time. 

INTERNAL TREATMENT. 

With regard to the question of internal treatment, which is one 
of pressing importance, it can safely be said that there are no remedies 
to be given by the mouth that can be described as certainly and spe- 
cifically curative of the diseases of the skin. The number of medicinal 
agents employed with this end in view is incredibly large, by far the 
greater part being obtained from the vegetable kingdom. With few 
exceptions, some of which are enumerated below, the most esteemed 
of these agents exert only an indirect therapeutic effect upon the in- 
tegument. The larger number of medicaments thus used are, it must 
be admitted, without value of any kind, but will probably continue to 
be vaunted as possessing specific virtue so long as credulity on the one 
hand, and avarice on the other hand, move the mass of mankind. 

Arsenic has long stood at the head of the list of remedies as valu- 
able, when ingested, for the relief of cutaneous disorders. It is known 
to exert its effects almost exclusively upon the epithelia of the skin, 
and upon these, so far as therapeutic effects are concerned, only when 
they are the seat of subacute and chronic exudation. It is known to 
exert an unfavorable influence upon the epidermis when the latter is 
in a condition of active inflammation, and if given for long periods of 
time may produce pigmentation of the skin of the general surface of 
the body and keratosis of the palms and soles. Operating favorably 
in this limited class of cases, it also operates slowly, requiring months 
for the production of its curative effects. Its administration is at all 
times attended with the hazard of producing toxic effects, which, hoAv- 
ever, when the result of the exhibition of the drug in medicinal doses 
are usually limited to a mild exanthem upon the skin, moderate coryza, 
and some redness from congestion of the vessels in the eyes and eyelids. 

Arsenic is used chiefly in psoriasis, acne, squamous eczema, pem- 
phigus, and lichen ruber its doses in cases of children being rela- 
tively large. It should invariably be administeted only after eating, 
and a minimum dose be first employed in order to test the suscepti- 
bility of the patient to its action. It should be remembered that the 
toxic effect of this, as also of several of the other drugs mentioned 
below, is often speedily noticed after the first exhibition of a relatively 
small dose. Toleration once established, the dosage may be cautiously 
increased. 

The forms in which arsenic is usually administered are : the prepa- 
rations of arsenious acid, such as the popular tablet-triturates made 
up in different and most commonly administered doses ; the liquor po- 



INTERNAL TREATMENT. 87 

tassii arsenitis (Fowler's solution) ; the liquor arsenici et hydrargyri 
iodidi (Donovan's solution) ; the liquor arsenici chloridi (de Valan- 
gin's solution) ; and the Asiatic pill. Duhring's modification of this 
pill is obtained by making 2 grains (0.13) of arsenious acid, and 32 
grains (2.2) each of black pepper and licorice powder into thirty-two 
pills by the aid of a sufficient quantity of gum Arabic and water. 
Arsenic is also at times advantageously combined with other indicated 
medicinal substances, such as iron and potassium iodide. 

An unprejudiced view of the value of arsenic, even in cases prop- 
erly selected for its internal administration, justifies the conclusion that 
it is in diseases of the skin a remedy of uncertain effect, and in that 
proportion disappointing. After collation of the experience of ex- 
perts it has been shown that the common practice of giving arsenic in 
many cutaneous diseases is both harmful and irrational, not merely 
because of its effect in inducing cutaneous congestion and pruritus, 
but also because of the reliance placed upon it to the exclusion of 
other and better methods of treatment ; and that the beneficial effects 
supposed to follow its administration are often due to other causes. 
No series of carefully recorded cases has ever been published in which 
notable therapeutical results have been shown to result solely from its 
administration. Even in pemphigus, psoriasis, chronic eczema, and 
lichen ruber, in which arsenic has been thought to possess special 
efficacy, it has in cases conspicuously failed. 

It is safest to conclude, first, that arsenic, instead of being one of 
the earliest, should be one of the last remedies to be selected in the 
management of cutaneous diseases by the general practitioner ; secondly, 
that, when thus selected, its value will probably prove greatest if the 
eruptive lesions be seated superficially, be generalized, diffused, or in 
evident association with neurotic symptoms ; thirdly, that in any case its 
failure to relieve should not be regarded as definite, if only Fowler's 
solution has been administered. 

Mercury is a remedy of the greatest value in cutaneous as in other 
affections. Its specific action upon the liver and intestinal secretions 
calls for its employment in many cases in which intestinal elimination is 
deficient, in which there is habitual constipation, and in which there is a 
decided tendency to congestion of the blood-vessels of the head, of the 
anogenital region, and even of the low T er extremities. In all of the 
distinctly gouty dermatoses, in all eczemas of the florid-faced type of 
patients, in many cases of intense pruritus resulting from toxic influ- 
ences, and in almost all the eczemas of infancy and childhood, calomel, 
blue pill, and the gray powder are well nigh indispensable in securing 
the speediest and happiest results. Indeed, there are few adult patients 
seeking relief from a simple inflammatory affection of the skin and 
having at the same time a coated tongue, an offensive breath, and a 
loaded colon, who will not be benefited at the outset of treatment 
by free catharsis under the influence of a mercurial. In many cases 
indeed of aggravated types of engorgement of the skin, localized or 
generalized, a dose of blue mass may be given at night, on successive 
nights, or for a fortnight or more, and followed by a saline laxative in 
the morning, with the best effect upon the exanthem present. 



88 GENERAL THERAPEUTICS. 

Mercury in the treatment of syphilodermata is of incontestable value, 
and its injudicious employment in many cases springs from that pre- 
cise fact. The vulgar prejudice that many disorders of the skin, really 
not syphilitic, are obscure manifestations of lues in a preceding genera- 
tion and amenable to mercurial treatment, is a striking illustration of 
the necessity of accurate diagnosis in cutaneous diseases. When 
syphilodermata are present corrosive sublimate is often superseded, in 
consequence of its irritative effects, by the compounds of the metal 
with iodine. The gray powder is useful chiefly in case of infants and 
children, though its not infrequent development of the corrosive chlo- 
ride has limited its employment. Calomel and the mercurial pill should 
be employed only for transient eifect, as when administered for long 
periods they are much more than the other preparations mentioned 
likely to produce ptyalism. 

Iodine and its compounds are also chiefly used in syphilitic disorders 
of the skin, but they possess a wider range of value than the mercurials 
in the treatment of other cutaneous affections. Here, too, the abuse of 
the drug furnishes a long list of cutaneous disorders either originated 
or aggravated by its employment. As in the use of arsenic, toleration 
should be established before large doses are exhibited. The compounds 
chiefly used are the iodides of potassium, sodium, lithium, and ammo- 
nium ; and iodoform. Iodine has been administered for the relief of the 
scrofulodermata, lupus, keloid, psoriasis, and syphilitic affections of 
the skin. As to the latter, it may be added that in the earlier symp- 
toms of lues it is often a source of positive injury. 

Cod-liver Oil is a remedy of special value in diseases of the skin, 
and was for that reason held in high favor by the distinguished Hebra, 
though its action is almost exclusively that of a nutrient of the general 
system. It is employed chiefly for its roborant effects, which are 
similar to those of the digestible aliments. Its special value in the 
treatment of infants and children affected with cutaneous diseases can- 
not be questioned. It is, moreover, of great use in maturer years, and 
is advantageously exhibited in eczema, lupus, scrofula, syphilis, scle- 
roderma, and in all disorders of the integument accompanied by 
wasting. 

Cathartics, Alkalies, and Diuretics have an important place in 
the list of remedies valuable in the management of skin-affections. 
Cathartics are chiefly valuable in eliminating effete or toxic products, 
but they are effective also in reducing congestion of the body-surface. 
The value of mercurials in this connection has been already suggested. 
The saline laxatives and cathartics also are of great service, especially 
the magnesic and sodic sulphates, and the Rochelle, Carlsprudel-^ and 
Hunyadi Janos salts. The useful and frequently ordered mistura 
ferri acida is compounded as follows : 



R Magnes. sulphat., ^jss ; 45 

Acid, sulph. arora. (vel dilut.), 3j ; 4 
Ferri sulphat., gr. viij ; 

Aq. menth. piper., ad giv ; 120 



50 

M. (filtra). 



Sig. A tablespoonful in hot or cold water before breakfast daily. 



INTERNAL TREATMENT. 89 

The alkalies are extremely useful in all cases of gouty disorder, and 
in erythema, acne, and certain forms of eczema. The carbonates of 
sodium, potassium, and lithium are chiefly employed, as well as the 
liquor potassse. The prevalent misconception of the value of lithium 
carbonate aud other salts of the same base has produced a reaction 
which suggests a preference of one of the other alkalies when such are 
indicated. v Diuretics, with the exception of water, are less valuable in 
cutaneous than in other affections, but they yet are administered often 
with special advantage in inflammatory disorders. 

Water when drunk in sufficient quantities and at proper times is 
of great value as a diuretic and as an aid to elimination. Soft water 
is to be preferred, and should be drunk freely at all times except dur- 
ing meals and for an hour after eating. The best results are obtained 
by drinking a given amount (four to eight, or more, ounces) every hour. 
As such a course is usually impracticable outside of hospitals and 
health-resorts, under ordinary circumstances two or three glasses may 
be ordered to be taken on rising in the morning and before meals. 
The free use of water, especially if iced, with meals is a fruitful source 
of indigestion as a consequence of the chilling and large dilution of the 
stomach-contents. The vicious habits of rapid eating and imperfect 
mastication of food may often be corrected by simply abstaining from 
the drinking of liquids during the taking of food. 

Quinine, administered both as a tonic and an antiperiodic, is largely 
employed in cutaneous medicine for its generally recognized systemic 
effects. It produces, in susceptible individuals, a peculiar smoothness 
and softness of the skin, which usually disappear when the drug is 
suspended. Like arsenic and iodine, it is occasionally the cause of a 
generalized exanthem, and is capable of producing other toxic effects, 
such as failure of the heart's action, dizziness, and tinnitus aurium, 
symptoms recognized under the designation of cinchonism. It will, of 
course, exhibit its happiest effects in malarial affections with coincidence 
of cutaneous symptoms in the form of disease of the skin associated 
with a neurosis. 

Salol is a remedy of special value in many cutaneous disorders asso- 
ciated with intestinal sepsis. It is particularly useful in the forms of 
pustular acne when the subject of the affection has an habitually coated 
tongue, a foul breath, and defective 'digestion. 

Ergot and Ergotine, whether by exerting an effect upon the muscle- 
bundles or the vessels of the derma, or upon the uterus, or yet by its 
influence upon the general economy, is thought to possess some value 
in the treatment of several cutaneous diseases occurring in both sexes. 
Such are acne, purpura, and a few other disorders. 

Calx Sulphurata was once regarded as the most efficient of the 
sulphur compounds for internal use in cutaneous diseases. Its sup- 
posed value in furunculosis has led to its employment also in eczema, 
acne, and impetigo. It is given in doses of from -^ (0.004) to \ 
(0.016) of a grain, three or four times daily. It is, however, a remedy 
uncertain in operation and of dubious effect. 

Ohrysarobin has been administered internally by Stocquart * and 
1 Ann. de Derm, et de Syph., 1884. 



90 GENERAL THERAPEUTICS. 

others, in doses of \ (0.01) of a grain, for a number of cutaneous 
disorders. 

Ichthyol, mentioned later as of some value when externally em- 
ployed, has also been given by the mouth. 

Jaborandi and Pilocarpine, probably as a result of the free dia- 
phoresis which they excite, unquestionably exert immediate thera- 
peutic effects in a number of cutaneous disorders. 

Sulphur, highly esteemed as a popular remedy in cutaneous affec- 
tions, exerts but little influence upon the latter when it is ingested. 
Its cathartic effect is the chief reason for its administration. It is 
recommended by Crocker in some of the disorders of the sweat-function. 

Antimony in small doses is of unquestioned value in many diseases 
of the skin. It is, when not contraindicated, employed with advantage 
in psoriasis, pruritus, and some of the obstinate forms of eczema. 

Tar, Carbolic Acid, Creosote, Guaiacol, Resorcin, Turpentine, 
Copaiba, and Phosphorus are remedies which have been employed 
internally with appreciable effect in certain cutaneous maladies. They 
have been used with advantage in cases of lupus, eczema, psoriasis, 
and pruritus ; but the disagreeable effect of their internal administra- 
tion has been to a great degree a bar to their general employment. 
The "perles" of phosphorus and the elixirs of the same drug obviate 
this difficulty in the instance of at least one of these articles. Creosote 
carbonate given in capsules is usually well tolerated. 

Animal Extracts, Thyroid Extract, and other preparations of the 
thyroid, adrenal, and other glands of the larger mammals, have in recent 
years been employed largely in various diseases of the skin. In myx- 
cedema decided and brilliant results have been obtained, and the same 
is true of ichthyosis, psoriasis, and some tuberculous affections of the 
skin. The depressing action of thyroid-extract on the heart makes it 
an unsafe remedy to use except with great care. 

Maltine, and other preparations of malt alone or in the valuable 
combinations now on sale, are of marked value in promoting the nutri- 
tion of the skin. They are especially indicated where there is imper- 
fect digestion of the carbohydrates, and where fats are not readily 
assimilated. They are useful in acne, in scleroderma, in syphilis, in 
tuberculosis of the skin, and in many of the cachexias accompanied 
by cutaneous symptoms. 

Iron and its several compounds are invaluable in the management 
of a long list of cutaneous disorders. Iron is indicated in many cases 
of cachexia and struma ; in tuberculosis of the skin ; in syphilis ; in all 
the anaemias ; and in many cases of purpura and pemphigus. Fortu- 
nately, iron is often well assimilated when compounded with other drugs, 
and hence has been suggested the long list of compounds of iron and 
mercury and of iron and iodine in syphilis ; of iron and quinine and of 
iron and the vegetable bitters in anorexia and ansemia ; and of iron with 
cathartics in atonic constipation. 

The Analgesics have occupied a small space in cutaneous medicine, 
and that space should be more and more restricted. The use of acetan- 
ilid, of opium and its alkaloids, of phenacetine, of potassic bromide, 
of trional, of sulphonal, and of articles of the same class, has been 



INTERNAL TREATMENT. 91 

indicated for relief of the tormenting pruritus, pain, and insomnia 
accompanying a long list of dermatoses. Unfortunately, most of the 
preparations devised to insure relief, after a temporary calmative effect 
have a decidedly aggravating influence upon the exanthem present. 
To a degree scarcely noticeable in other cases have drug-habits been 
formed in consequence of the temporary assuagement of the local dis- 
tress when under the influence of an analgesic. As a rule, the most 
competent physician is he who secures relief for his patient without 
narcotizing the nerves which are uttering their protest by abnormal 
sensation. The expert reserves for the last extremity an ordering of 
medicines of the anodyne class in attempting to secure relief. 

Hypodermatic and Intracutaneous Injections of alcohol, arsenic, 
mercury, cocaine, carbolic acid, the alkaloids of opium, antitoxins, 
exalgine, of erysipelas-toxins, and other substances have been largely 
employed in the management of cutaneous disorders, some with 
marked success, others with doubtful results. The most brilliant of 
the achievements in this direction are without question the relief of 
the syphilodermata by deep intramuscular injections of mercury. The 
injection of the antitoxins which have been such a boon in an important 
group of general disorders has, on the whole, proved disappointing in 
cutaneous medicine. Attention has been directed to the special objec- 
tions in most of the affections of the skin to the use of anodynes and 
opiated medicaments by whatever route introduced into the system. 
The temporary alleviation, when secured, is gained at too great a cost. 

Tuberculin (Koch's lymph), Thiosinamine, Taurine, and yet 
other substances have been injected subcutaneously in the management 
of lupus, acne, eczema, psoriasis, lepra, and other affections. They 
have not as yet such an acceptance at the hands of the profession as 
would justify their employment in any save specially selected cases. 

Spraying the skin for antiseptic purposes is of value, and may be 
often employed with marked advantage. The several solutions of for- 
malin are best suited to the purpose. Frigorific sprays for the purpose 
of freezing a part of the skin selected for operation, as in the case of 
epithelioma, are indispensable to the operator. Those chiefly employed 
are discharged from bulbs containing ethyl chloride. 

Natural Mineral Waters. — The chief value of many of the mineral 
springs and health-resorts of the United States lies in the change of 
the manner of living that they invite and necessitate. Sunshine, pure 
air, recreation after the care and toil of business, change of climate, of 
foods and drinks, and even of cooks, often decide the question of 
speedy recovery. Unfortunately, both in America and in Europe, 
many of the health-resorts are peopled by unscrupulous charlatans, 
with a tendency to attribute all the benefits to be derived from these 
sources to the medicinal virtues of this or that particular spring, aided 
always by treatment according to their own peculiar methods. Many 
patients affected with disease of the skin are thus made worse by a 
temporary residence at noted health-resorts, and, therefore, it is often the 
case that a visit to the seashore, to the mountains, or to any healthful 
place in the country proves conducive to greater practical results. 
None the less the springs of America and Europe having mineral con- 



92 GENERAL THERAPEUTICS. 

stituents, in many instances supply a valuable means of treating cuta- 
neous diseases. The sulphur waters of Richfield Springs, of Sharon 
Springs, and of Avon Springs, in this country, as of those of Europe, 
operate chiefly by an influence exerted upon the digestive tract ; the 
springs of West Virginia are examples of calcic waters having for the 
most part a diuretic effect. The fine water of the Poland Spring in 
Maine is chiefly valuable by reason of its remarkable purity. The 
alkaline waters of Colorado Springs, of Saratoga, and of other sources 
in America are rapidly securing a reputation equal to that of the 
famous Vichy, Carlsbad, and Ems of Europe. 

The chemical laboratories, however, are fast placing at the disposal 
of the consumer the salts, either natural or artificially produced, which 
represent the constituents of most of the waters highly esteemed, both 
here and abroad, in the management of disease. In this way the 
Apenta, Hunyadi Janos, Hathorn, Kissengen, Congress, Friedrich- 
shall, Rakoczy, and other waters may be produced at will by solution 
of the proper salts in water : and the latter in many of our large cities 
is now furnished after distillation and aeration in such purity that it 
competes with distilled water in the laboratory of the chemist and in 
the operations of the photographer. 

Of the chalybeate and arsenical waters, the former abundant in 
Michigan and New York, the latter best represented by that of Levico, 
in the Austrian Tyrol, it may be said that their use is often followed 
by excellent results, especially when the drinking of the water is as- 
sociated with the tonic regimen and healthful environment of the 
springs from which these waters are obtained. 

EXTERNAL TREATMENT. 

In the external treatment of diseases of the skin the indications are 
to hasten repair when this is possible ; to alleviate distress if palliatives 
only are admissible ; to destroy absolutely or excise the diseased tissue 
when this is justifiable. The following are the principal substances 
employed as external applications : 

Water, either pure or medicated by holding substances in solution 
or mechanical suspension, is applied either in baths or as lotions. 
Baths, local or general, may be employed for days continuously or but 
for a few moments at a time. They are given with water varying in 
temperature — cold, warm, or hot. Rain-water is to be used when 
practicable. 

Cold baths of short duration are generally followed by a sharp re- 
action, the skin becoming congested after the normal temperature of 
the surface is regained. It is for this reason that cold sponging of the 
inflamed skin is usually grateful so long as it is continued, and is suc- 
ceeded by an aggravation of the symptoms which it was intended to 
relieve. Continued applications of cold water are not open to this 
objection. 

Hot baths are followed by a more or less enduring relaxation of the 
integument, while tepid water-baths are chiefly macerative of the sur- 
face. Hot baths are valuable in several of the exudative and hyper- 






EXTERNAL TREATMENT. 93 

trophic affections of the skin. It should be remembered that the 
application of watery lotions to the broken surface of the skin is likely 
to be followed by endosmosis, unless the specific gravity of the serum 
of the blood and that of the fluid of the bath or the lotion are nearly 
the same. This imbibition of fluids by the broken skin is accom- 
panied by slight swelling of the tissues and is productive of disagree- 
able sensations. 

The continuous warm water-bath in which the patient is immersed 
either for the greater part of a day or for a few hours at a time is an 
exceedingly valuable means of treating pemphigus, the severe grades 
of burns, and ulcerative affections of the skin. 

The most perfect of all applications of water to the surface of the 
body is that most resembling the water-bath in which the tender 
skin of the foetus is immersed for consecutive months. Here the 
bath is continuous ; the temperature is that of the viscera of the 
living animal ; and the delicate skin of the unborn child is anointed 
with a fatty substance which interferes with the macerative action of 
the surrounding fluid so long as the vitality is preserved at the average 
standard. The comfort and therapeutic value of a bath prepared and 
administered in approximation to this ideal can scarcely be overesti- 
mated. Were it not for the difficulties with which it is attended, so 
far as relates to many portions of the surface of the body, it would 
be possible with this single therapeutic measure to rob the exudative 
affections of the skin of many of their formidable features. 

Vapor, steam, Russian, and Turkish baths are less valuable than is 
usually supposed in diseases of the skin. The macerative effect they 
produce is not always desirable. They possess some value in severe 
general pruritus, in ichthyosis, and in keratosis pilaris. 

In acute inflammations of the skin the application of pure water, 
even when of proper temperature, is often prejudicial to the integu- 
ment, and soap-and-water washiugs may prove quite harmful. The 
greatest caution must be exercised in giving instruction to patients as 
to the washing of the inflamed skin. 

Water for external application, as in the bath, is medicated by the 
addition of a large number of substances, such as marine salt, boric 
acid, corrosive sublimate, sodic and potassic salts, alum, tannin, the 
mineral acids, gum Arabic, gelatin, and bran.* 

The alkaline bath, made by adding sodium bicarbonate or biborate 
to water having the proper temperature in the proportion of 12 ounces 
of either salt to 30 gallons, is usually grateful to the inflamed skin. 
Sulphur-baths are best prepared by adding an ounce of Vleminckx's 
solution l to the above-mentioned quantity of water. 

The natural Sulphur-baths of Eichfield Springs and Avon Springs, 
in this country, are efficacious in certain cutaneous affections accom- 
panied by roughness and thickening of the integument. 

1 The formula is : 

R Calcis, ^ss; 16 

Sulphur, sublim., Sj ; 32 

Aq. desk, ^x ; 3201 M. 

Coque ad ^vj [200] deinde filtra. 

Sig. " Vleminckx's Solution." 



94 GENERAL THERAPEUTICS. 

Tar-baths are usually given by first anointing the skin of the patient 
with the tarry substance to be employed, and by immersing the body 
in warm water for some hours afterward. The resulting effect can 
usually be accomplished as well by other measures. 

Salt- and Marine Baths possess the highest value with respect to 
the general health of the individual ; and are advantageously employed 
over the body-surface when, for example, the head alone is affected 
with a dermatosis (rosacea, acne, erythema), and when the salt is not 
brought into contact with the morbid surface. In very many cases 
a sea- or salt-bath produces aggravation of a cutaneous affection, and 
indeed, in some cases, is capable of begetting the same. A properly 
directed salt-bath or lotion, however, is at times positively beneficial, 
not merely in chronic, but also in acute affections of the skin. 

The strength of the usual marine salt-bath is \ pound to the gallon, 
though 10 pounds of the salt are often added to 25 gallons of w T ater 
with advantage. The sea-salt is not preferable to the article obtained 
from the natural brine-wells of the interior of the country. For 
invalids the skin of the body may first be well rubbed with the finest 
table-salt well warmed in an oven, after which a tepid or warm bath 
may be used to cleanse the surface. 

Antiseptic Baths are most often employed by the surgeon. In the 
management of skin-affections local baths of boric acid in hot or cold 
water may be employed. The acid is soluble in about 25 parts of cold 
water. Corrosive-sublimate baths are employed in the strength of 1 
drachm (4.) of the mercurial to 30 gallons of water. Local baths thus 
medicated are often employed in the cleansing of ulcerated and suppur- 
ating surfaces with a view to subsequent dressing. 

When employed as a lotion, water is made to produce a sedative 
effect by the addition of opium, belladonna, glycerin, carbolic acid, 
hydrocyanic acid, zinc, bismuth, mercury, lead, and alkaline bicarbon- 
ates with the sodic biborate. It is rendered stimulating by the ad- 
mixture of alcohol, most of the acids and alkalies in stronger solution 
than in the soothing or sedative lotions, and also by a large number of 
substances which operate upon the surface either mechanically or 
chemically. Water is also rendered astringent when tannin, lead, and 
similar medicaments are dissolved in it ; and by its union in various 
proportions with soaps an'd alkalies a solvent effect is produced, either 
upon the cuticle itself or upon pathological or foreign products upon 
its surface. 

Soaps. — Soft soap (sapo viridis, sapo mollis) made by the addition 
of caustic potash in an excess of between 3 and 4 per cent, to an 
animal fat, is a substance exceedingly useful in the treatment of skin- 
diseases. It is used for the purpose of producing either a detersive or 
stimulating, and at times a slightly destructive effect either upon the 
surface of the skin itself or upon pathological accumulations upon the 
surface (crusts, scales, etc.). It may be used as a plaster or with 
water : and this last either in substance or by the aid of the widely 
known "Spiritus Saponis Alkalinus" which Hebra first devised: 2 
ounces of green soap to 1 ounce of alcohol, flavored with spirit of lav- 
ender. The hard or soda soaps are employed chiefly for toilet purposes. 



EXTERNAL TREATMENT. 95 

"Over-fatty" or "superfatted" soaps, both soda and potash soaps, 
are neither alkaline nor neutral in reaction, but contain a slight excess 
of unsaponified fat. They are exceedingly mild in their detersive 
action upon the skin, though the lather produced in their use is not so 
abundant as that with the alkaline soaps. These are usually proprie- 
tary articles. 

Medicated Soaps, containing carbolic acid, glycerin, tar, sulphur, 
and various oils, are sold in the shops ; but they usually contain so 
small a portion of the individual medicament from which each is 
named that they are practically worthless except for purposes of ablu- 
tion. Under cold pressure they may be made to contain medicinal 
substances in therapeutic proportions, but other forms of administra- 
tion of such medicaments are preferable. 

Fatty and Oily Substances are applied to the skin either directly 
by pouring, or by friction, or by the mediation of compresses, bandages, 
etc., which are saturated or are spread with the material to be applied. 
The oils may be used for either nutritive, soothing, or stimulating 
effects. To the first and second classes belong cod-liver, lard, olive-, 
almond-, linseed-, neat's-foot, castor-, and similar oils ; to the third class 
belong the oil of tar, of cade, of white birch, of the cashew-nut, and 
of juniper. 

Fatty substances are also applied in the form of ointments or 
pomades. They are compounded with various medicinal substances, 
according to the requirements of each case, such as the salts of mer- 
cury, zinc, copper, lead, and sulphur; pyrogallol, chrysarobin, carbolic 
and hyposulphurous acids ; tar, camphor, iodoform, balsam of Peru, 
chloral hydrate, and the extracts of opium, belladonna, etc. 

The products of petroleum refinement known as Vaselin and 
Cosmolin, though not true fats, are increasingly employed for similar 
purposes, and continue to enjoy high favor in America and in Europe. 
They are particularly useful as bases for ointments for application to 
the hairy portions of the body, such as the scalp, where more consistent 
salves paste the hair to the surface in an unsightly mass. 

In the class of soothing ointments which are required in many 
cases in which the skin is the seat of a severe pruritus or is produc- 
tive of burning sensations, may be named the diachylon, benzoinated 
zinc-oxide, " cold-cream," lanolin, cucumber, petroleum, diachylon, 
spermaceti, cacao-butter, and olive-oil with vaselin ointments. Those 
medicated with the several oleates and with the salts of bismuth, zinc, 
or lead, are often of great value. As a rule, however, in most cases 
calling urgently for soothing applications fat-containing dressings are 
not to be preferred to lotions or dusting-powders, or the two last named 
in combination. Ointments are rubbed gently over the affected sur- 
face, but they are more efficient when spread on bits of soft muslin and 
kept in contact with the skin. 

McCall Anderson's ointment has long been employed for soothing 
inflamed surfaces. It is compounded by adding 1 drachm of bismuth 
oxide (4.) to 1 ounce (30.) of oleic acid, 3 drachms (12.) of white wax, 
9 (36.) of vaselin, and a few minims of the oil of roses. 10 parts of 
lanolin, with 20 of lard and 30 of rose-water, make another useful 



96 GENERAL THERAPEUTICS. 

combination. Many of these ointments in the past have been found to 
be irritating on account of the fatty acids which they develop, especially 
in hot weather. They may now all be kept perfectly sweet by the 
addition of a small quantity of formalin to each jar compounded. 

The following formulae are also useful : Boric acid, white wax, and 
paraffin, each 10 parts ; oil of sweet almonds, 60 parts (H. Hebra). 
Bismuth oxide, 1 drachm (4.) ; white wax, 6 drachms (24.) ; vaselin and 
olive-oil, of each 1 ounce (30.). Boric acid, 1 part ; glycerin, 24 parts ; 
anhydrous lanolin, 5 parts; vaselin, 70 parts (Duhring's " boroglycerin 
cream ointment "). Other fatty applications are prepared by adding 
olive-, sweet-almond, or cotton-seed oil, as well as lard and lanolin, to 
lime-water in nearly equal proportions. These furnish a thick emulsified 
substance which requires to be well shaken before application. Any 
one of these emulsions may be medicated at will by the addition of 
zinc, bismuth, calamine, or other insoluble substance which is mechani- 
cally mixed with the fatty emulsion w T hen the whole is well shaken. 

Stimulating ointments are usually made by the addition of such 
substances as tar, mercury, resorcin, salicylic acid, pyrogallic acid, 
chrysarobin, or sulphur to any one of the several salve-bases in com- 
mon use. 

Glycerin, even the best, when applied in its purity to the skin is 
usually irritating. It is, however, exceedingly useful when diluted or 
made a component part of lotions and ointments. When combined 
with starch in different proportions it makes a series of combinations 
known as glyceroles, or glycerolates. These combinations are pasty, 
semisolid substances which are capable of varied medication, as in the 
glycerole of lead subacetate. They are useful chiefly as protectives 
of the skin-surface. Glycerin, used in a fluid soap, is an exceedingly 
valuable agent when a milder effect is desired than that produced by 
the spirit of soap described above. The Vienna preparation known as 
Sarg's fluid soap is an admirable substitute of this sort when a soft 
shampoo is required for the scalp. 

Pastes employed for local application in diseases of the skin have 
greatly been perfected by Lassar and Unna. 1 

These pastes are valuable especially in the exudative affections, in 
which salves are often either not well tolerated or actually prove irritating 
to the skin. The pastes, when applied to such surfaces, form a pro- 
tective and adhesive dressing, which may be medicated as desired. One 
of the best and most serviceable pastes is : 



B Zinc, stearat. cum acetanilid., ] 

01. oliv., V aa £ij. 

Unguent, aq. ros., j 

Or the following modification of Lassar's paste : 



M. 



R Zinci oxidi, "j -- *... 

Taic, j aa 3y; 8 

Acid, salicylic, gr. x ; 

Vaselin., Jss ; 16 

1 Monatsch. f. prakt. Derm., February and March, 1884. 



66 
M. 



EXTERNAL TREATMENT. 



97 



Equal parts of lanolin, vaselin, talc, and zinc oxide form a base that 
is stiffer than the preceding and adheres better. To these bases may be 
added various remedies in desired proportions. 

Duhring's modification of the original Lassar paste is : boric acid, 
9j (1.); starch and zinc oxide, each 3ij (8.); vaselin, ^j (33.). Unna 
employs : starch, 3 parts ; glycerin, 2 parts ; water, 15 parts ; boiled 
down to 15 parts. Half the quantity of any desired medicament may 
be added to the amount ordered. Paraffin may be added in the making 
of very stiff pastes in the proportion of equal parts of this substance 
and water; twice the quantity of lanolin ; and about ^V of white wax. 

Other pastes are prepared with kaolin (terra alba, or Armenian bole 
of red color when it is desirable to have the application resemble the 
color of the skin), gum, lead, dextrin, glycerin, and other substances. 
Formulae for each are here appended. 

Kaolin in a pure state, with equal parts of vaselin or glycerin, or 
with almond-, olive-, or linseed-oil, in the proportion of two to one, is 
readily applied in a thin layer over the skin. 

For making lead-pastes, litharge is boiled with twice the quantity of 
vinegar until the latter has evaporated and there is left a damp but 
drying paste, which may be, on occasion, remoistened with a small 
quantity of vinegar, e. g.: 

R Lithargyr. subt. pulv., ^jss ; 45 

Aceti, ly'ss; 75. 

Coque usque ad consistent, pastse: deinde adde ol. lini [v. glycerini, v. ol. 
olivse], 10.— M. 

In the two forms of paste above described the adhesive and desic- 
cative qualities are obtained from the main ingredients, but in those 
resulting from combinations of gum, starch, and dextrin these results 
are for the most part obtained by the addition of other ingredients, such 
as sulphur, zinc, etc. A good basis, semisolid, rapidly drying, and 
fixing its ingredients well upon the surface, is the following: 



R Zinci oxidi, 


3J ss ; 


45 


Acid, salicylic, 
Amyli oryzse, 1 
Glycerini, j 
Aq. dest., 
Coque ad., givss (145). 


3ss; 
aa 3iij ; 

^ijss; 


2 

12 
75 


)r a sulphur-paste : 






R Sulphur, prsecipit., 
Calc. carb., 


5ss; 


45 
2 


Zinc, oxid., 


^ss; 


15 


Amyli oryzae, 
Glycerini, 
Aq. dest., 
Coque ad., §iv (120). 


3iij ; 

,^ss; 
lijss ; 


12 
15 

75 



To make use of dextrin, the official pulverized article is selected, 
and a simple paste of this forms a good drying base. An added half- 

7 



98 



GENERAL THERAPEUTICS. 



weight of glycerin is required if powders are also combined with the 
paste — e. g.: 

R Zinc, oxid., 

Dextrin., 

Aq. dest., 

Glycerin., 

Sulphur, sublim. [vel sod. 
sulpho-ichthyol.] , 
Coque. 



3 J ss ; 


45 


33 3SS 5 


15 


^jss; 


45 


3ss; 


2 



A mixture of dextrin and lead is thus prepared : 



B Lithargyr., 
Acet., 

Coque ad remanent., 50. 

Adde : 

Dextrin., 1 
Aq. dest., > 
Glycerin., J 

Coque. 



3jss; 



aa ^ss; 



30 
45 



151 



If too consistent, these pastes are made to spread easily by the 
addition of a few drops of hot water. 

For gum-pastes, gum Arabic is used in the proportion of 1 part 
of the mucilage and glycerin to 2 parts of the powder selected, mixe^ 
without heat — e. g. : 



B 



R 



B 



Zinc, oxid., 




S jss ; 


45 


Hydrarg oxid. rub., 




3ss; 


2 


Mucilag. acac, | 
Glycerin., J 


aa 


^ss; 


15 


Cret. prasparat., ) 
Sulphur, sublim., j 


5 5 


3ss; 


2 


<X CK 




Picis liquid., 




3ij; 


8 


Amyli, 




^ss; 


15 


Mucilag. acac, 1 
Glycerin., } 




_ 


15 


aa 


3 s s ; 


Acid, salicylic, 




^ss; 


15 


Glycerin., 




^ss; 


15 


Mucilag. acac, 




3j; 


30 


01. ricini, 




Sijss ; 


10 



M. 



M. 



M. 



The following details are to be noted respecting the availability of 
these pastes for different ingredients : Lead is best used as an acetate, 
either in a simple paste or with dextrin, the carbonate, oleate, and 
iodide combining well with both. Zinc oxide and sulphur combine well 
with kaolin, lead, starch, dextrin, and gum. Sulphur combines well 
with the three last named, poorly with kaolin, and not at all with lead. 
Ichthyol suits well with all save the gum-pastes. Naphtol, calomel, 
corrosive sublimate, red and white precipitates, carbolic acid, chloral 
hydrate, camphor, and salicylic acid can be incorporated with all, the 
last named in smaller proportion with gum-paste. Tar is better united 
with starch, dextrin, and gum than with the others. Iodine and iodo- 




EXTERNAL TREATMENT. 99 

form naturally do not suit well with the starch- and dextrin-pastes. 
Chrysarobin and pyrogallol are united with kaolin and gum-pastes, 
and should not be added to them. Fatty and soapy substances, if , 
commingled in large amounts with these pastes, injure their special 
properties. 

Glycogelatins are useful for protecting a surface and excluding the 
air. They are made with varying proportions of glycerin, gelatin, zinc 
oxide, and water. When cold they are solid, but when melted on a 
water-bath can be painted readily over a surface, upon which on cool- 
ing they form an adherent protective coating. Before the gelatin has 
hardened on the skin it is well to pat it with cotton, or to lay over it a 
piece of thin gauze or muslin to form an additional protection and to 
prevent the paste sticking to the clothing. A firm but soft and flexi- 
ble gelatin is made by mixing on a hot-water bath 1 part of zinc 
oxide, 2 of gelatin, 3 of glycerin, and 4 of water. More gelatin in the 
preparation makes it firmer and causes it to dry quicker. A greater 
proportion of glycerin, on the other hand, interferes with the complete 
drying of the surface, but makes a softer preparation, more acceptable 
to some skins and very useful where a bandage can be applied. Zinc 
oxide helps give body to the gelatin, but if used in too large proportion 
interferes with the coherence of the preparation, so that it cracks when 
dry. To the glycogelatins may be added white precipitate, sulphur, 
ichthyol, thiol, chrysarobin, iodoform, or other antiseptics. Some drugs, 
as salicylic acid, resorcin, naphtol, and carbolic acid, tend to destroy 
the coherence of the gelatin. Fox says that this obstacle may be 
removed by adding to the paste 5 or 10 per cent, of fresh lard. 

Varnishes, containing glycerin and a single gum, are often very 
serviceable in protecting the skin. They are especially useful on the 

£as they are transparent and inconspicuous, 
^ck's varnish (linimentum exsiccans) is made as follows : 



R Tragacanth, 5 parts. 

Glycerin, 2 " 

Distilled water, 93 " 



The tragacanth is soaked in a portion of water from ten to twelve 
hours and triturated to a perfectly smooth mass before adding the glyc- 
erin and other ingredients ordered. The jelly may be prepared without 
delay by triturating the tragacanth with boiling water, but the result is 
not quite so good. 

This jelly is applied without heating and quickly dries on the skin. 
An improvement on this varnish is Elliott's bassorin paste, which keeps 
better than the former. The formula is as follows : 

R Bassorin, 
Dextrin, 
Glycerin, 
Water to make 

This should be kept in a tightly closed jar, as it dries rapidly on 
exposure to the air. Like the other pastes, it not only serves as 

LofC. 



3jss ; 


45 


5vj; 


24 


Sijss ; 


10 


Siij ; 


90 



100 GENERAL THERAPEUTICS. 

a protective coating, but also as a base for the application of other 
remedies. 

Powders are mechanically dusted over the surface of the skin 
for the purpose of protecting it, and occasionally, also, to produce 
an astringent or antipruritic effect. To be serviceable, they should 
generally be rendered impalpable by sifting them carefully through a 
fine silk bolting-cloth. They are composed of starch, talc, magnesia, 
lycopodium, calamine, bismuth, boric acid, the several stearates, cam- 
phor, tannin, zinc oxide, iodoform, rice, kaolin, magnesium silicate, 
orris root, salicylic acid, aristol, europhen, and similar substances. The 
articles sold by grocers as " gloss starch " and " corn-starch farina " 
are usually much more finely bolted than the dusting-powders extem- 
poraneously prepared by chemists. All starchy substances are open 
to the objection of forming little pasty rolls or " cakes " when wetted 
with serum or with sweat. Lycopodium, which consists of irregularly 
shaped globular pollen-sporules, never behaves in this way, and is, 
for that reason, deservedly popular. Zinc stearate with acetanilid is 
excellent for similar reasons, and when dusted on the surface forms 
a dressing impervious to moisture. 

Medicated powders may be first dissolved in alcohol, ether, or 
chloroform. The solution is then mixed with starch or with French 
chalk. Evaporation of the menstruum is conducted without artificial 
heat, and a fine medicated starch or a chalk-powder results. 

For absorbent purposes Grundler 1 has shown that by far the most 
effective powder is magnesium carbonate. 

Plasters are employed when it is desired to exert a more or less 
continuous effect upon the skin, and are thus necessarily consistent 
and desirable. The resin-plasters are less useful in skin-diseases be- 
cause more irritating than the lead-plasters. In the zinc-oxide adhe- 
sive plaster the irritating effects of the resin have been entirely over- 
come, and the result is a plaster which has excellent adhesive qualities 
and which rarely causes irritation even to sensitive skins. It thus 
answers admirably where simple protection is desired, and may be 
safely employed in order to retain other dressings in place. Unna's 
plaster-mulls are described below. The mercurial plasters are useful, 
especially in syphilitic lesions of the skin. 

A valuable addition to the list of methods for applying medicated 
ointments to the skin has been devised by Unna. His Salve-muslins, 
or salve-mulls, are strips or bandages of muslin thoroughly impreg- 
nated and thickly spread with ointments medicated with almost every 
desirable substance, from zinc oxide to tar, thymol, salicylic acid, and 
mercury. They are elegantly made, and when exported are sur- 
rounded by impermeable tissue, so that they remain fresh and sweet 
for several weeks, or even for months if kept in a cool place, but de- 
teriorate rapidly if exposed to the air of a warm room. They are 
efficacious, and, as a rule, well liked by patients. They are available 
in skin-diseases of the exudative class affecting the extremities, but 
should be avoided when not recently prepared. 

Unna's Plaster-mulls seem to be less useful. They are plasters 

1 Monatshft. f. prakt. Derm., 1888, No. 20. 



EXTERNAL TREATMENT. 101 

thinly spread on gutta-percha cloth, and manufactured with a wide 
range of medicinal constituents. They serve a good purpose in the 
protection of parts of the skin exposed to friction. 

Salve-pencils (stili unguentes) and Paste-pencils (stili dilubiles), 
the latter destitute of fat and soluble when moist, the former insol- 
uble in water and compounded of fatty substances, are pencil-sized cray- 
ons made with Avax, gum, and starch, for application to limited areas 
of the skin. The several mercurials, arsenious acid, cocaine, salicylic 
acid, and other medicaments may be applied in this way to the surface. 

Poultices are not often ordered in the management of diseases of 
the skin, except for the purpose of softening crusts with a view to their 
removal. They are made, both warm and cold, with linseed-meal, 
potato-starch, bread and milk, oatmeal, and cornmeal. These applica- 
tions are objectionable in all conditions in which a macerative effect of the 
epidermis is produced ; and also in whioh micro-organisms may find a 
culture-field in the mass of the poultice. Poultices, in any needful 
case, may be made antiseptic by the addition of formalin, boric acid, or 
mercuric chloride. 

Lanolin, or wool-fat, was first introduced as a salve-base by Lie- 
breich, of Berlin. It is a substance obtained from keratinic tissues, 
and contains cholesterin-fat instead of glycerin, with but 30 per cent, 
of water. It has a bright-yellowish color, a distinct odor of the sheep, 
and is neutral ; when pure it is never acid in reaction. The refined 
product now placed upon the market is free from cholesterin com- 
pounds and requires no fatty addition. This substance is readily 
absorbed from the surface of the skin, and, either pure or medicated, 
may be regarded as a useful addition to the bases of ointments. The 
adeps lana3 answers the same end. 

Oleates of zinc, mercury, copper, lead, and other metals have been 
employed with advantage in the topical treatment of disorders of the 
skin. Of these, the oleates of mercury and of lead are decidedly the 
most valuable. The latter is represented by Hebra's white diachylon 
ointment. The mercuric oleate is serviceable in syphilitic, parasitic, 
and other disorders. 

The Vasogen products bid fair to supplant the oleates in their 
ready absorption from the skin-surface. In mercurial inunction vaso- 
gen-mercury capsules supply the exact amount required for employ- 
ment at each sitting. 

Collodion and Traumaticin are employed for the purpose of ap- 
plying a remedy to the skin, and at the same time for protecting or 
contracting the surface to which the application is made. Traumaticin 
is the name given to a solution of gutta-percha in chloroform, in the 
proportion of 10 per cent. In this way bismuth, cantharides, sulphur, 
chrysarobin, zinc oxide, white precipitate, iodine, and other substances 
may with advantage be applied to the surface, and the action of each 
be definitely limited to the margins of a single patch of disease. 

Tar in its several varieties, crude and distilled, together with its 
derivatives, occupies an important place among efficient topical agents. 
In general, it seems to exert upon the epidermis a local influence, 
which extends more deeply as the remedy is continuously applied. At 



102 GENERAL THERAPEUTICS. 

times both irritative and inflammatory effects are thus induced, and 
even systemic intoxication when absorption from the skin occurs. Pix 
liquida, or the oleum picis, is the favorite article of this group with 
most American physicians ; but the oleum cadini, or oil of juniper, 
and the oleum rusci, or oil of birch, are rather more generally em- 
ployed by experts. The last-named, found in purity and abundance 
and to be had at a low price in American markets, is recommended 
above the others. In Vienna the distilled oil is preferred, but there is 
good reason to believe that the crude oil is decidedly more efficacious. 

The skill of a physician intrusted with the management of a disease 
of the skin might almost be measured by his success in the use of tar. 
He who has not had experience in its employment is urgently advised 
to select one member of the tar-family and learn thoroughly how to 
apply that, singly and in combination, either as a lotion or in salve. 
Properly employed, it will favor involution of lesions, lessening hyper- 
emia, infiltration, scaling, and discharge. It serves admirably as an anti- 
pruritic. It may, however, produce severe inflammation of the skin. 

To produce the benign or emollient effects of tar, it is best mixed 
with some soothing or astringent powder, and with this end in view 
nothing is better than chalk. Spender's hints 1 for making such an 
ointment are admirable : Finely levigated chalk is strewed into melted 
lard in a stone jar, the whole being stirred until it is cold. Then at 
first the smallest quantity of tar sufficient to make a brownish smear 
of color is added to the quantity of salve employed for use. This 
color can be successively deepened at will. Auspitz advises the use 
of the tars in a pure state, applied in very small quantities with a 
strong bristle-brush and well rubbed in. In combination with one of 
the most valuable of all substances for topical use in cutaneous thera- 
peutics, viz., sulphur, tar enjoys a special reputation. The Wilkinson 
salve modified (q. v.) represents such a combination. 

A group of substances which occupy a therapeutic position inferior 
to the tars, but which serve an important end in the management of 
cutaneous diseases by the production of similar effects, are carbolic 
acid, creosote, salicylic acid, benzol, naphtol, iodol, thiol, chrysarobin, 
pyrogallol, resorcin, and jequirity. 

Ichthyol, fish-oil, introduced to the profession by Unna, is the 
distillate of a bituminous and sulphurous deposit of petrified fishes 
and marine fossils found in the Tyrol. Its chemical formula is 
C 26 H 36 S 3 Na 2 6 . It has a tarry appearance, odor, and consistency. It 
is soluble in water, partly so in ether and alcohol, and can be incor- 
porated in any desired proportion with fat, vaselin, and lanolin. It 
has been used both pure and diluted ; and several proprietary articles 
(plasters, soaps, salves, and medicated cotton) are in the market. It 
has been used both in America and in Europe in cases of leprosy, 
pruritus, acne, sycosis, eczema, psoriasis, and a number of other cuta- 
neous disorders. 2 It is used in solutions of from 10 to 50 per cent. 

1 Practitioner, June, 1883, p. 402. 

2 See Baumann and Schotten : Monatshft. f. prakt. Derm., 1883. Unna : Ibid., 
1882; Dent. med. Zeit., 1883. Samml. klin. Vort., 1885; Lorenz : Deut. med. Woch., 
1885; Stelwagon: Jour. Cutan. and Ven. Dis., ]886, p. 326; Zeisler: Chicago Med. 
Jour, and Exam., 1886. 






EXTERNAL TREATMENT. 103 

and -in salves of from 5 to 20 per cent, strength. As before stated, it 
is also administered internally, more particularly in the management 
of rheumatism, in doses of from 1 5 to 20 drops. It does not seem to 
have a disturbing effect upon the stomach. 

Unpleasant results have been reported as following its application 
in a single instance (Sinclair). A four months' old infant sank into a 
stupor two hours after its head and limbs were smeared with a salve 
composed of one part of ichthyol to five of vaselin. 

Thiol makes an excellent substitute for ichthyol for most purposes, 
and lacks the unpleasant odor of the latter. 

Resorcin in ointments of the strength of from 5 to 20 per cent, 
serves as an antipruritic and alterative. Stel wagon reports an anodyne 
effect following its use. The same experimenter has modified Ihle's 
formula by adding 1 drachm (4.) of resorcin to 1 to 2 drachms (4.-8.) 
of castor-oil, 5 minims (0.33) of Peruvian balsam, and 4 ounces (120.) 
of alcohol, for use in alopecia and seborrhoea of the scalp. It is a 
valuable parasiticide in lotions of the strength of from 5 to 10 per 
cent., and is especially useful in disorders of the scalp due to seborrhoea. 

Naphtol, or /3-naphtol, as it is termed chemically, first introduced 
by Kaposi, is chiefly valuable in scabies, but has also been used in the 
management of eczema, psoriasis, and other exudative affections. Van 
Harlingen 1 has found it to answer well in seborrhoea of the scalp. 
Neisser has described renal disorders as resulting from its use in chil- 
dren, but MM. Josias and Nocard 2 report that in ordinary medicinal 
doses it is harmless. The fact that the naphtol preparations are odor- 
less and do not stain the skin is to be set down in their favor. 

Boric Acid is of great value in oliseases of the skin and is exten- 
sively employed as a lotion and in ointments and powolers. As a rule, 
it exercises a seolative effect upon the surface to which it is applied. 
Over mucous surfaces it is occasionally a source of moderate irritation. 

Salicylic Acid operates especially upon the keratinized tissues of the 
epidermis, softening and separating the external portions of the horny 
layer from its deeper connections. For this reason it has a special 
value in all the hyperkeratosic dermatoses. In somewhat weak strength 
it is employed as an antipruritic agent. It is most often employed in 
salves or pastes but is also used in lotions, being soluble in 2.5 parts 
of alcohol, 2 parts of ether, or 450 parts of water. It is a common 
ingredient of most of the popular corn- and wart-cures. 

Carbolic Acid, since in value as an antiseptic it has been largely 
surpassed by other articles, is chiefly employed to-day upon the skin 
as an antipruritic. It is applied in the form of lotion, salve, and 
paste, but much more often in lotions having the strength of from 
10 to 20 grains to the ounce (0.66-1.33 ad 30.). Other acids — nitric, 
sulphuric, lactic, acetic, muriatic, benzonic, tannic, chromic — are em- 
ployed either for caustic, destructive, or stimulating effect, usually in 
liquid form. Tannic acid, however, is occasionally employed as a 
powder, in which form its astringent quality is combined with the 
soothing or antiseptic effect of other substances in poAvder. 

1 Araer. Jour. Med. Sci., Oct., 1883. 

2 Ann. de Derm, et de Syph., May, 1885. 



104 GENERAL THERAPEUTICS. 

Chrysarobin, Pyrogallol, and Anthrarobin are useful as cutaneous 
stimulants capable of determining in the skin to which they are applied 
a characteristic dermatitis limited to the site of the application. Chrysa- 
robin is especially useful in the local treatment of psoriasis, lepra, 
and the disorders due to vegetable parasites. It is employed in from 
1 to 10 per cent, strength, in salve, lotion, or in collodion. A useful 
combination in the parasitic disorders of the scalp due to the micro- 
sporon Audouini or to the trichophytons is a solution of chrysarobin in 
oil of turpentine, about 1 part in 250. A chief objection to its use is 
the consequent staining of the skin and articles of apparel. On the 
scalp the hairs are turned to a yellowish-green shade. Pyrogallol 
oxidizes after exposure and turns the skin a blackish color. It is 
useful in many cases of lichen planus, eczema, and the diseases due to 
the vegetable parasites. It has been employed in the strength of 50 
per cent, in the removal of epitheliomata. Anthrarobin, though in- 
ferior to both of the other articles named, is effective in the same gen- 
eral manner. 

Iodine, especially in the form of tincture, is useful as a local appli- 
cation in certain of the seborrheas, and as a parasiticide. It is often 
employed with mercury in the form of an ointment. The ointments 
compounded of the salts of iodine, with mercury, though of unques- 
tioned efficacy, are less employed to-day than formerly. 

Jequirity (Abrus precatmus), employed by ophthalmologists for 
the purpose of inducing artificial inflammation of the conjunctiva, has 
been used by Shoemaker * in the management of lupoid and other 
ulcers. One part of the cleansed, decorticated, and bruised grains, 
macerated for twenty-four hours, and reduced by rubbing in a mortar 
to a smooth paste, was added to sufficient water to make four parts. 
This emulsion was used for local application. 

Sulphur, popularly employed chiefly as a laxative or for the local 
treatment of scabies, has also a deserved reputation in cutaneous thera- 
peutics as an external agent in a wide range of non-parasitic disorders. 
Hebra once regarded it as valueless in eczema, but his opinions on this 
point are not now generally accepted. Precipitated sulphur is to 
be preferred to the other compounds of the pharmacopoeia. It may 
mechanically be incorporated with salve-bases, or chemically combined 
with vaselin and other petroleum-products, a process by which, as 
experiments have shown, its therapeutic value is not increased. It is 
also applied after mechanical union with various substances as a lotion. 
It is irritating to the acutely inflamed skin, but is much better tolerated 
than the tars in conditions of subacute or chronic exudation. 

Formaldehyd is a valuable antiseptic agent most commonly em- 
ployed as formalin, a proprietary preparation representing 40 per cent, 
of the compound. Formalin in the strength of 1 per cent, commonly 
produces a slight irritation over the thin skin of the face ; and after 
application in the strength of 2 per cent., which should be rarely 
exceeded on the cutaneous surface, there follows a decided sensation 
of burning with a resulting transient erythema. It is a remedy of 
the highest value in the treatment of syphilodermata, acne, seborrhea, 

1 Lancet, Aug., 3884, p. 185. 



EXTERNAL TREATMENT. 105 

the disorders produced by the vegetable parasities, several of the 
eczemas, impetigo, and other affections. It is well to color the solution 
with a trace of fuchsin. 

Pyoktanin-blue is employed in aqueous saturated solution as a 
parasiticide in those disorders of the skin especially which affect regions 
beneath the clothing or which may be protected by dressings from ex- 
posure to the eye. It is highly valuable as a local and painless appli- 
cation in circumscribed patches of weeping or scaly eczema, in many 
of the ulcerating syphilodermata, in lupus, and in ringworm. It 
should be applied daily in several coats, each coat being permitted to 
dry before the next is superimposed. 

Potassium Permanganate belongs to the same category as pyok- 
tanin-blue, with the disadvantage that it is in some strengths produc- 
tive of pain, while the pyoktanin solution is unproductive of pain. 
From 2 to 10 per cent, solutions of the potassic salt may be painted 
on the affected surface one or more times daily till the desired effect 
is produced. The indications for its use are those which the pyok- 
tanin solution is intended to meet. 

Mercury and its compounds are of value in the local treatment of 
many disorders of the skin, syphilitic and non-syphilitic. The prepa- 
rations of mercury employed as topical agents in the treatment of 
diseases of the skin are of the highest value. They include corrosive 
sublimate, calomel, the red and yellow oxides, the biniodide and cinna- 
bar, the white and red precipitates, and the nitrate. The most com- 
monly employed of their combinations are the " black wash," oint- 
ment of the nitrate, and mercurial ointment. Fumigation of the 
surface by vaporization of either cinnabar or calomel or the two in 
combination is chiefly employed in the local treatment of syphilo- 
dermata. The bichloride is most often applied as a lotion ; calomel 
and white precipitate in ointments ; though calomel is often effec- 
tively combined with talc or starch as a powder. Startin's nitric oxid 
of mercury ointment represents a combination of two mercurials : red 
mercuric oxide, 6 grains (0.40) ; mercury bisulphate, 4 grains (0.25) ; 
simple cerate, 1 ounce (30.). Corrosive sublimate as a parasiticide is 
of great importance in the treatment of several cutaneous disorders due 
to the presence of micro-organisms, as, for example, lupus vulgaris. 

Chloral- camphor and Phenol- camphor have value chiefly as anti- 
pruritics. The former is obtained by rubbing together chloral hydrate 
and gum-camphor (Bulkley) until they form a clear liquid of pungent 
odor. Phenol-camphor is made by gradually adding camphor to melted 
crystals of carbolic acid, a colorless liquid resulting having the fragrant 
odor of camphor without that of the acid. It is a useful local anaes- 
thetic agent, being insoluble in water, but freely soluble in chloroform, 
ether, and alcohol. 

Many Agents are employed upon the surface of the integument to 
produce in various degrees a caustic or destructive effect. Among 
these may be named the thermo-cautery (Paquelin-knife), galvano- 
caustic apparatus, the mineral acids and alkalies, sodium ethylate, 
arsenic, zinc chloride, several mercurial compounds, mercuric nitrate, 
mercuric chloride, antimonious chloride, cupric sulphate, and argentic 



106 GENERA L THERAPEUTICS. 

nitrate. Several of these substances in weak solution are employed as 
milder agents for the production of irritative or even inflammatory 
effects. To the latter class should be added iodine in tincture, chloro- 
form, tartar emetic, croton-oil, and cantharides. These destructive 
effects are of advantage in the treatment of disorders of the integu- 
ment due to parasites, either animal or vegetable. Of those employed 
for this purpose, and not mentioned above, may be named petroleum 
and staphysagria, for the destruction of lice ; sulphur, styrax, and 
balsam of Peru, for the destruction of acari ; and sulphur and its com- 
pounds and a number of derivatives from tar, for the destruction of 
vegetable parasites. 

Counter-irritation over the Vasomotor Centres, as recommended 
by Crocker, is an efficient means of relieving fixed and obstinate cuta- 
neous disorders. It may be produced by the action of sinapisms, 
blisters, or caustics over the region selected for such irritation. 

A large list of medicinal substances might be added which are oc- 
casionally employed in cutaneous affections, some very rarely, the most 
with questionable effect. Among them may be named alcohol, which 
is of high value as a disinfectant, and hydrogen peroxide, having a 
similar effect ; ether, the opium alkaloids, cocaine, belladonna, cannabis 
indica, and aconite, for anaesthetic and antipruritic effect; and ergot, 
cantharides, mustard, croton-oil, tartar emetic, benzoin, capsicum, rose- 
mary, and the several salts of lead. Many of the articles named, such 
as cantharides, rosemary, and capsicum, are employed as lotions for the 
scalp in the several alopecias. 

The salts of zinc (sulphate, sulphocarbolate, acetate, oxide), of copper, 
alum, lead, bismuth, and other metals are of service in diseases of the 
skin as productive of both astringent and stimulating or even of caustic 
effects. The careful adjustment of the dosage in each instance is of the 
highest importance, and is practically indispensable for the production 
of beneficial effects. 

Electrolysis is a method of the greatest value in the treatment of 
a large number of cutaneous affections, such as hypertrichosis, telan- 
giectases, molluscous tumors, warts, etc. It is accomplished by the 
aid of the galvanic battery in the manner described in this work in the 
pages devoted to the first of the disorders named. 

The Minor and other Surgical Operations required in the manage- 
ment of some affections of the skin are detailed in the treatises devoted 
to that subject. Among such procedures may be named skin-grafting, 
both by the methods of Reverdin and Thiersch, and the several devices 
of plastic surgery. Strictly dermatological procedures to which resort 
must often be made are : epilation in hyphogenous sycosis and other 
affections ; massage, especially by the massering-ball ; the operations 
on the face, especially in acne, when opening small abscesses, removing 
comedones, and incising papules ; and multiple scarification, as in telan- 
giectases and other lesions. 

Numerous Surgical and other Appliances are found useful as 
adjuvants in the treatment of skin-diseases. They may be employed 
to support, protect, or compress the surface, or merely to aid in the 



EXTERNAL TREATMENT. 



107 



retention of dressings or external medicaments. Thus, the ordinary 
roller-bandage is applicable to many portions of the body ; the suspen- 
der, or suspensory bag, to the scrotum ; elastic or inelastic stockings 
to the feet and legs ; kid, rubber, and thread gloves to the feet and 
fingers ; and various skull-caps, face-masks, and mittens are employed 
in the case of infants and children to protect affected surfaces from the 
traumatisms of scratching. 

Apart from the surgical apparatus required for ablation of tumors 
or severe operations, a number of instruments are required for the 
daily use of the dermatologist. Among these may be named : 

A set of variously sized dermal curettes. These sharp-edged spoons 
are for erasion of the surface, and should, for general use, have in each 
a fenestrum large enough to permit the escape from the floor of the 
spoon of all collected substances. The small-sized spoons, however, 
with solid bowl and sharp edges, largely used in Vienna, are prefer- 
able for use, especially about the face, in many skin -affections. Epilat- 
ing-forceps, with easy springs and smooth blades meeting in perfect 
apposition ; a set of Piffard's comedone-extractors, provided at each 
extremity with a differently sized, minute, spoon-shaped and perforated 
bowl, the convex surface of which is pressed over the comedo with the 
orifice immediately over the black head of the plug. This is a great im- 
provement over the old-fashioned comedo-extractor shaped like a watch- 
key, and the discomfort to the patient by its use is greatly reduced. 
A set of half-inch and four-inch lenses for examining the surface of the 
skin ; needle-holders with light handles for firmly grasping the needles 
used in opening pustules, etc. The needles, some of them, should 
be flat, with a double-cutting edge, others be rounded neatly on an 
emery-wheel, and all of them carefully disinfected if used more than 
once. Too many precautions cannot be taken in the practice of der- 
matology with respect to the disinfection of all instruments made to 
penetrate the skin. Probes, exploring-needles, fine dressing-forceps, 
delicate straight and curved scissors, and other instruments from the 
ordinary pocket-case of the surgeon, are indispensable. The instru- 
ments required for use in connection with the galvanic battery are 
enumerated in the chapter on Hypertrichosis. 

Fig. 23. 



Irido-platinum needle. 
Fig. 24. 



^*- 



Miliiim-needle. 
Fro. 25. 



Searifying-spnd. 



108 



GENERAL THERAPEUTICS. 




Epilating-forceps. 
Fig. 27. 




Piffard's grappling-forceps. 
Fig. 28. 




Piffard's cutisector. 
Fig. 29. 




Fig. 30. 




Dermal curettes. 
Fig. 31. 




T.IEMMM-GQ-NX 



Hess's glass pleximeter, for observing the skin under pressure. 

Fig. 32. 



Piffard's modification of Unna's comedo-extractor. 
Fig. 33. 

o '^4 of real size. 

Keyes's cutaneous punch. 

Fig. 34. 




Hyde's massering-ball. 



VIII. CLASSIFICATION. 



The numerous attempts which have been made to classify diseases 
of the skin according to their nature and relations have been in response 
to the generally recognized demand for a systematic arrangement of all 
scientific facts. As regards dermatology, not only have these attempts 
been numerous and based upon different principles, but the results which 
they have accomplished have also been in the highest degree divergent. 
No classification yet devised has secured general acceptance. While it 
is certain that no one system of classification has been perfect, and that 
each has exhibited defects, it is equally true that of the large number 
each has possessed some merit of its own. No perfectly satisfactory 
classification of cutaneous diseases can be made until the knowledge of 
diseases of the skin has been greatly enlarged. 

One of the most acceptable of the systems thus far proposed is that 
of Hebra. In it cutaneous disorders are arranged in the following 
nine classes : 

Class 1. Disorders of secretion. 

Class 2. Hyperemias. 

Class 3. Exudations. 

Class 4. Hemorrhages. 

Class 5. Hypertrophies. 

Class 6. Atrophies. 

Class 7. New Growths. 

Class 8. Neuroses. 

Class 9. Parasites. 
Since this classification was devised by Hebra none has been pro- 
posed which compares in ingenuity with the arrangement made by 
Auspitz. The principle of this classification is to place together those 
diseases and groups of diseases which present a clinical unity, the general 
pathological process being the predominant characteristic for selection ; 
individual characteristics, such as symptoms, localization, anatomical 
peculiarities, etc., being only brought thus predominantly forward when 
coinciding with the real nature of the class, the group, or the skin- 
disease in question. 1 Auspitz's nine classes are : 

1. Simple Inflammatory Dermatoses ; 2. Angioneurotic Dermatoses; 
3. Neurotic Dermatoses ; 4. Stasic Dermatoses ; 5. Hemorrhagic Der- 
matoses ; 6. Idioneuroses ; 7. Epidermidoses ; 8. Chorioblastoses ; 
9. Dermatomy coses. 

Under these classes, by the aid of divisions and subdivisions, an 
elaborate scheme is presented which embraces not only all cutaneous 

1 System d. Hautkrankheiten. Wien, 1881, 

109 



110 CLASSIFICA TION. 

diseases, but also all pathological processes recognized in the skin. 
The mere presentation of this system has been followed by an advance 
in the nosology of cutaneous medicine more satisfactory than any since 
the contributions to this subject by Hebra. 

Auspitz's classification, however, is open to various objections on the 
part of the student of dermatology. It is elaborated to the extent of 
placing the names of some diseases in more than one family, and hence 
is confusing to the beginner. It is better adapted to the needs of the 
expert than of the student, for it introduces to the study rather of 
morbid processes in the skin than of the complexus of those processes 
which are recognized in disease. 

Whether the principle of classification be anatomical, etiological, or 
pathological ; whether it be based on the processes actually occurring 
in the skin, or on those deeper factors and forces which operate cen- 
trifugally upon the skin, and on which that organ depends for all its 
functions and even its existence ; whether it proceed etiologically from 
causes which are immediate or those which are remote, it is easy to see 
that, as knowledge in each of these directions enlarges, the exact position 
of any one disease in any given classification must be rendered insecure. 
Never was this observation more suggestive than at this day, when the 
pathogeny of numerous skin-disorders is revealed in the light thrown on 
the subject by the discovery of hitherto unknown inferior organisms. 

Indeed, to this last cause, awakening grave doubts as to the precision 
of much that was once esteemed fact, may be attributed the declining 
interest in the general subject of classification of diseases of the skin. 
The solution of its problems has practically been deferred by common 
consent to a date when the questions thus suggested can more satisfac- 
torily be answered. Several recent writers have contented themselves 
with an alphabetical indexing of the names of skin-diseases as an order 
useful simply for reference. 

The arrangement of titles of diseases of the skin in this treatise is 
a modification of the scheme first proposed by Hebra on the lines recog- 
nized by the American Dermatological Association in its classification 
adopted in 1884. In the successive editions of this w T ork which have 
appeared since this classification was first accepted, changes from time 
to time have been made ivhich were rendered necessary by the advance- 
ments of science. As the arrangement stands to-day it should be 
regarded as a mode of grouping diseases for the convenience of the 
student rather than as an attempt at a scientific classification of diseases 
of the skin. 



DISEASES OF THE SEXN". 



CLASS I. 
DISORDERS OF THE GLANDS. 



In this class of disorders are grouped the functional affections of the 
sweat-glands, or coil-glands, the sweat-pores, and the sebaceous glands. 
These disorders may be betrayed in quantitative or in qualitative 
changes in the secretion, or in retention of the latter in the whole or 
in a part of the secretory apparatus. When a disease of the skin 
ceases to be purely functional in type, and is accompanied by an exud- 
ative process, glandular or periglandular in situation, such disease 
is properly classed with another group of affections. With a view, 
however, to convenience of arrangement there have been placed in 
this class a few dermatoses which cannot be regarded as strictly func- 
tional affections. 

1. DISORDERS OF THE SWEAT-GLANDS. 

HYPERIDROSIS. 

(Gr. virep, in excess ; vdup, water.) 

(Idrosis, Hydrosis, Ephidrosis, Sudatoria, Polyidrosis, 

Hyperhidrosis.) 

Hyperidrosis is an exaggerated quantitative effusion of sweat, the 
.secretion accumulating in visible drops upon the surface of the skin. 
Symptoms. — This condition may be physiological, as the result of 
active exertion in a medium of high temperature ; or it may be patho- 
logical in character, and in the latter case be either general or partial. 
General sweating to a pathological extent chiefly occurs in the obese, 
jbut also in those who are the subjects of constitutional disease (phthisis, 
(the various febrile disorders, etc.). It is the fertile source of the vari- 
ous forms of intertrigo, sudamina, and miliaria. Local hyperidrosis 
is the exaggerated quantitative effusion of sweat limited to certain defi- 
nite portions of the skin, as the palms, the soles, the dorsa of the 
rhands and feet, the interdigital spaces, the genitals, the axilla?, and the 
temples. In such cases the secretion occurs moderately or greatly in 

ill 



112 DISORDERS OF THE GLANDS. 

excess, varying in this respect somewhat in different degrees of tem- 
perature and in rapidity of the circulation ; it is occasionally, but not 
commonly, accompanied by fetor. It may involve one or both sides 
of the body, being generally symmetrical upon the extremities and 
asymmetrical upon portions of the face. 

Its topical expression may be studied in the hands, which are con- 
tinually moistened, clammy, or dripping with fluid within a brief time 
after the most careful drying of the parts. In the case of a woman, 
the instincts of whose sex prompt her to take such precautions, the 
dress is constantly protected from contact with the macerated palms 
by a handkerchief or similar article which is always in readiness. The 
disadvantages thus arising in individuals of both sexes who are en- 
gaged as tradespeople, artists, hand-workers, etc., are obvious. In 
women of social position no small complaint is made of the disagree- 
able result produced after wearing kid gloves for even a short time, 
the material of which is soon soiled by its complete saturation with the 
secretion from the skin. 

With and without this local excess occurs the hyperidrosis of the 
feet, aggravated by the mechanical force of gravity and the need of 
constant covering. The stockings and the leather of the boots, shoes, 
or gaiters are saturated with the secretion, and rapidly become subject 
to chemical alteration. There is usually an offensive odor of the re- 
gion, originating partly in the primary fetor of the secretions them- 
selves, and partly in the subsequent chemical decomposition of the 
latter, rapidly progressing under the influence of the soiled and often 
stinking investments of the feet. 

The integument, constantly macerated, may become both painful 
and tender ; occasionally there is vesiculation or exfoliation of patches 
of sodden epidermis. When the genitals are involved, especially in 
men, erythema and intertrigo are the frequent results. 

Etiology. — The disease is frequently recognized in persons suf- 
fering from an habitually rapid or slow pulse or from organic cardiac 
disease ; in rare cases it is congenital. In other instances it is asso- 
ciated in one person with disorders not apparently related to it. In 
the case of a hospital-patient recently examined, a woman, twenty- 
four years of age, was affected with severe tylosis of the feet, from 
which were exfoliated extensive lamellated casts of the soles. She had 
also typical hyperidrosis of the hands. 

In no portion of the nervous system has a localized centre for excito- 
sudoral or inhibitory effects been recognized. Traumatisms, gliomata, 
gummata, scleroses, and other lesions affecting the cerebrum, medulla, 
cord, ganglia, and trunks of the sympathetic nervous system have 
been followed by local hyperidrosis, but they have all repeatedly failed 
to induce such morbid sudoral symptoms, while a fit of anger or sudden 
fright has been as conspicuously effective as any. In short, the pre- 
dominant influence of the nervous system in an etiological sense must 
be admitted here as in physiological sweating, and to the sympathetic 
branches of that system must be assigned the greater influence for most 
cases. A paralysis or paresis of the sympathetic is held to explain the 
occasional coincidence of pulmonary and cardiac disorders with either 



HYPERIDR OSIS. 1 1 3 

general or partial excessive sweating. Compression of the sympathetic 
by adenomata, aneurisms, carcinomata, etc., has been followed by 
marked symptoms of this disorder. The disease is encountered in 
individuals of both sexes, and in all ages and degrees of general health, 
as also in those who are and those who are not cleanly. There is 
reason to believe that the facial asymmetrical hyperidroses associated 
with migraine, neuralgias, hemicrania, etc., are etiologically and path- 
ologically distinct from the similar symmetrical affections of the hands 
and feet. The last-named disorders certainly occur with conspicuous 
frequency in young women who are the subjects of hysteria, chloro- 
ansemia, some form of dysmenorrhea, or cardiac trouble. 

Pathology. — Robinson, who examined a number of sections from 
the palm of the hand, failed to detect any abnormal feature either in 
the glands or in the epithelium. The disorder is to be regarded as 
purely functional ; and any anatomical changes in the coil-glands 
or the sweat-pores are probably accidents of such derangement of 
function. 

Treatment. — When universal, hyperidrosis is to be treated internally 
by the aid of such remedies as are indicated by the general condition 
of the patient, and especially by the condition of the heart. The 
various ferruginous tonics, mineral acids, arsenic, strychnine, stroph- 
tmthus, quinine (the latter particularly when, as is often the case, a 
malarial affection is responsible for the disorder), and ergot, with both 
belladonna and atropine, are all of unquestioned value. Even though 
but temporarily serviceable, belladonna and atropine are well used at 
the outset of most cases. Aconite, jaborandi and pilocarpine, white 
agaric (agaricin is recommended in doses of -^ grain (0.011), repeated 
as required), carbolic and salicylic acids may be named as in the 
second rank. Meat should always be largely eliminated from the 
dietary. 

External treatment, which is often promptly efficacious, should not 
be neglected in any case. The simplest method is by wiping, not wash- 
ing, the skin-surface until it is dry, and applying a dusting-powder, such 
as lycopodium, talc, salicylic acid, boric acid, bismuth, magnesia, chloral 
hydrate (1 part to 5 or 6 of starch), or starch. Alternately with either 
of these, or in lieu of them, baths or lotions may be employed, aqueous 
or alcoholic, and medicated with corrosive sublimate, formalin (1 to 5 
per cent, solution), tannic acid, ferrous sulphate, naphtol (Kaposi), tur- 
pentine, zinc sulphate, alum, potassium permanganate, or common 
salt. Daily sponging of the affected surface with weak solutions of 
formalin (1 to 6 per cent.) will remove the odor, and will in most 
cases greatly diminish the amount of perspiration, but on suspension 
of the treatment the condition usually returns. Fox l advises a lotion 
containing 1 part of quinine to 100 of alcohol. Van Harlingen 
recommends the use of juniper-tar or carbolic-acid soap with the 
bath as alone sufficient to relieve some cases. Grosse 2 praises highly 
tannoform, either in powder (1 part to 2 of talcum) or as a 25 per 
cent, plaster. 

J Jour. Cutan. and Ven. Dis., 1885, p. 24. 
2 Klin, therap. Woch., 1899, Nos. 16 and 17. 



114 DISORDERS OF THE GLANDS. 

For hyperidrosis of the feet the treatment by the method of Hebra 
lias deservedly high repute. It consists in neatly and completely 
enveloping the entire foot, the toes separately, after thorough washing 
and drying, in strips of cotton-cloth over which is spread to the thick- 
ness of a common knife-blade the unguentum diachyli albi. This 
unguent is made by boiling 1 part of the best litharge with about 
4 parts of pure olive-oil, to which a little water is added while the 
materials are stirred together over a slow fire. The parts are well 
bandaged, and the patient either remains subsequently at rest or pur- 
sues his vocation, wearing over the feet shoes and stockings which 
have not previously been worn. In twenty-four hours the feet are 
redressed without washing, after dry rubbing with charpie and a dust- 
ing-powder. This treatment is repeated daily for from ten to twenty 
days, after wdiich a dusting-powder (boric acid) may be substituted 
for the local dressing. There occurs a parchment-like desquamation 
of the epidermis in thick, yellowish-brown lamella?, beneath which is 
formed a new and at first tender but apparently normal epidermis. 
When the latter has lost its tenderness the feet are for the first time 
washed Avith water. In case of failure the routine of treatment 
is repeated as often as requisite. It is scarcely necessary to add 
that no ill effects are known to have resulted from the therapeutic 
measures adopted in checking a local hyperidrosis. For the dia- 
chylon salve there may be substituted tar, ichthyol, or naphtol 
ointment. 

Gerdeck l makes three applications to the soles, at intervals of about 
eight hours, of the strongest solutions of formalin the skin of the indi- 
vidual will bear. In some instances full strength is well tolerated. A 
few drops are put in the shoes, the influence on the leather being pre- 
servative and not destructive. Relief follows for several weeks, when 
the treatment may be repeated. 

Fredericq employs finely pulverized tartaric acid, applied at first 
with some caution, and always in small quantities. Stewart first bathes 
the feet in hot water and then soaks them for a few moments, once 
only, in a solution of potassium permanganate, 4 to 6 grains to the 
ounce (0.266-0.4 to 32.), after which the plaster selected for use may 
be applied as directed above. Legoux orders pediluvia of tar-water 
twice daily for three days, followed by painting of the feet with a 
solution of iron perchloride. Morrow 2 recommends foot-baths in the 
extract of pin us Canadensis, followed by the application of boric acid, 
or of salicylic acid mixed with lycopodium. 

Prognosis. — The future of any case of hyperidrosis is uncertain. 
The disease, whether local or general, may spontaneously disappear, 
may recur, may promptly be amenable to treatment, or may prove 
obstinate to all therapy. Myrtle 3 reports the case of a male patient, 
seventy-seven years old, who sweated to death after repeated recur- 
rences of severe hyperidrosis, and after temporary relief from the use 
of Fowler's solution. 

•La Kiforma Medic;), 1898, No. 38. 

2 See his resume of this subject in Jour. Cutan. and Ven. Dis., vol. v., p. 68. 

3 Medical Press, Februarv''25, 1886. 



SUDAMEN. 115 

SUDAMEN. 

(Lat. sudor, sweat.) 

(Miliaria Crystallina.) 

Symptoms. — In this disorder the lesions are thickly agglomerated, 
but discrete, transitory, and translucent, pin-point-sized vesicles, re- 
sembling dew-drops or seed-pearls, upon the surface of the skin, often 
requiring the touch to define their real character. The lesions are 
usually -limited to certain regions of the body, as the trunk, and here 
more generally upon the front and sides of the belly and in the iliac 
regions, though they may occur upon any part. Their course is rapid, 
both in evolution and involution, and their sequelae are exceedingly 
delicate desquamative flakes, the thin roof-wall, which originally cov- 
ered the sweat-drops, having been lifted from the superficial stratum 
of the horny layer of the epidermis. They contain each a droplet of 
sweat, which is removed by evaporation. They are usually preceded 
by an attack of pruritus, and may follow the hyperidrosis of systemic 
debility, enteric and continued fevers, phthisis, inflammatory rheuma- 
tism, pneumonia, and other asthenic conditions. They may also result 
from violent exercise, the elevated temperature of the summer season, 

; flannel underclothing, vapor-baths, and the application of wet hot 
cloths to the surface of the skin. 

The lesions are the result of the accumulation of sweat in high tem- 

1 peratures of the external surface of the body or of the medium by 
which the body is surrounded, and usually in states of adynamia. The 
sweat accumulates between the most superficial layers of the stratum 
corneum. Sudamina mav hence occur at all a^es and in both sexes. 

Three forms of sudamina have been described : (a) sudamina alba ; 
(b) sudamina rubra ; and (c) sudamina crystallina. The last named is 
the only form to which the term suclamen is properly applied, since it 

i alone of the three designates a purely functional derangement of the 
sweat-secreting apparatus. 

The first term, sudamina alba (miliaria alba), is applied to the lesions 
occurring where there is maceration of the vesicular wall and when 
the contents become opalescent. This form is rare. The second term, 

j sudamina rubra (miliaria rubra, miliaria papulosa, lichen tropicus, 
" prickly heat "), is applied to inflammatory lesions which may accom- 
pany profuse sweating. These lesions are numerous pin-point- to pin- 
head-sized vesicles surrounded by a reddish halo, or papules of the 

i same dimensions, or the two lesions commingled, almost invariably 
accompanied by hyperidrosis, though the latter may be absent in high 

j temperatures. The marked tingling, pricking, and burning sensations 

j by which they are accompanied are often in the highest degree dis- 

I tressing, and may solicit rubbing of the affected part, though the 
scratching elicited by severe pruritus is not common. Minute crusts 

i may form after vesicular rupture. The attack may be mild or severe, 

' and may last for a few days or for a few weeks or months, the result 
of continuous aggravation or of the production of new crops of lesions 



116 DISORDERS OF THE GLANDS. 

after each recurrence of the cause. The affection is not rarely com- 
plicated in obese individuals by all varieties of intertrigo and eczema. 
Sudamina crystallina are, however, the sole lesions which may properly 
be referred to this class of affections. These vesicles are always free 
from inflammatory symptoms, presenting a limpid, dewdrop-like aspect 
that is characteristic. 

Etiology. — The disease is induced by excessive sweating, often in 
consequence of an elevated temperature ; also, however, as a result of 
a systemic asthenia, as indicated above. The vesicles may occur as 
symptoms of the death-agony. 

Pathology. — Robinson reports that the contents of the vesicles are 
pure sweat without admixture of lymphoid corpuscles. The fluid col- 
lects between the laminae of the deeper part of the corneous layer. A 
rupture of the wall of the sweat-duct may occur, but there may be instead 
obliteration merely of the sweat-pore by a sudden effusion of watery 
fluids toward the epidermis, that pass with moderate pressure through 
the wall-less sides of the pore into the spaces between the epithelial 
cells, where a chamber is readily formed. Torok found the walls of 
the vesicle composed purely of the corneous layer with a sweat-pore 
opening at the lower border of the chamber. 

Diagnosis. — No difficulty can arise in making a diagnosis if the 
peculiar characters of the sudamen be kept in view. All pustular 
lesions have different contents ; all bullous lesions are larger, or are 
seated on an engorged base, or they lack the limpid clearness of the 
sudamen, because, however transparent the contents, they are mostly 
covered by a thicker and less transparent roof. The halo about the 
lesions of miliaria rubra, or their rosy-pink shade, will determine their 
character. In varicella the lesions are chambered. 

Treatment. — Only the simplest treatment is required. Alkaline 
and bran baths may be employed, of the temperature most grateful to 
the skin. Afterward the surface may be dusted with one or several of 
the dusting-powders, such as starch, lycopodium, or boric acid, named 
in the chapter on General Therapeutics. The internal treatment is 
that indicated by the condition of the patient. 

Miliary Fever, " sweating sickness," suette miliaire of the 
French, is an epidemic disorder, accompanied by sweating and a cuta- 
neous exanthem. Pineau l gives a description of the disease as it oc- 
curred in epidemic form on the island of Oleron, where of one thous- 
and patients affected, between one hundred and fifty and two hundred 
perished. The eruption appeared in the form of hyperaemic maculae, 
disappearing under pressure, after which there rapidly formed myriads 
of reddish or whitish, grouped, unequally sized, acuminate papules, 
rising from a whitish and macerated surface. Among these papules 
were interspersed lesions of sudamina. The region of the face was 
not spared, and the conjunctivae were occasionally affected. In the 
course of from two to four days pinhead- to bean-sized, varioliform 
but non-umbilicated pustules formed in the site of some of the papules, 
the contents of which disappeared by resorption, the final lesions pre- 

1 Arch. gen. de Med., Jan., 1882, p. 25, 



HYDROCYSTOMA. 117 

sen ted being large, flat, reddish papules, the skin of the face partic- 
ularly becoming reddened and swollen. In the course of from ten to 
twelve days general desquamation ensued, with extensive palmar and 
plantar losses. Relapses occurred in some cases with diffuse redness 
of the surface or with crops of reddish plaques, or yet again with the 
occurrence of furuncles. The sensations were those of myriads of 
needles thrust into the skin. 

The exanthem was accompanied in some cases by fever. In the 
fatal cases death resulted from exhaustion. 

Geber and other writers, however, believe that the lesions described 
are not peculiar to any special disease, and they deny the possibility of 
an independent miliary fever. 

HYDROCYSTOMA. 

(HlDROCYSTOMA, CYSTS OF THE COIL-DUCT.) 

Robinson, of New York, in 1893, 1 published a report of his studies 
in this affection, which he first described eleven years previously, in a 
paper read before the American Dermatological Association. Reports 
of cases and studies of the disease have been made also by Hutchin- 
son, Jackson, Jamieson, Rosenthal, Hallopeau, and others. 

Symptoms. — The lesions are discrete or closely set, few or exceed- 
ingly numerous, tense, well-developed, clear, shining, pinhead- to pea- 
sized vesicles, never inflammatory and never superficially seated, that 
\ is, never as near to the surface as the vesicles of miliaria, because the 
base of all hydrocystomata is to be found in the corium. The lesions 
are Avhitish in color, or when of greater age and size are dark bluish, 
especially at the periphery, some resembling boiled sago-grains. No 
signs of inflammation are present. Occasionally a mild hypersemia 
becomes evident at the periphery of a single cyst. The contents are 
I pellucid, never changing to a yellowish hue, and when uninjured 
i resolve in time by desiccation, leaving a short-lived pigmentation. The 
I contents of the vesicles are always slightly acid. They are always 
accompanied by very free sweating. 

Etiology. — The disease occurs almost invariably in middle-aged 
i women, more often in those engaged as laundresses who have been 
sweating freely over the washtub, the face being simultaneously ex- 
i posed to warm vapor. There is usually aggravation of the disorder 
: in summer, and either complete or partial relief in winter. Aggrava- 
tion has been noted at the time of the menstrual period. One of 
Hutchinson's cases exhibited lesions on a single side of the face only. 
Robinson reports a case occurring in a young man. The few patients 
seen by us were all of the dispensary class, and were women who 
worked much over the w r ashtub. 

Pathology. — The epidermis, hair-sacs, and sebaceous glands are 

in all parts normal, the papillary layers being involved only when 

the cyst approaches the upper part of the corium, where " a thin plate 

j of flattened papillary body " is found above. Below, in places, the 

1 Jour. Cutan. and Gen.-Urin. Dis., August, 1893. 



118 DISORDERS OF THE GLANDS. 

lumen of the sweat-duct is found enlarged and distended with liquid 
and a granular material. The enlargement in the duct begins above 
the coil of the gland, and usually in the lower part of the corium. 
There is some perivascular leucocytosis in progress here and there in 
the vicinity of the vessels, but this was not a marked feature in any 
one of the several sections examined by Robinson. The cavities of 
each duct were found lined with epithelial cells. 

Diagnosis. — The lesions of sudamen and pompholyx are readily 
distinguished by their superficial character and their situation, as they 
are rarely discovered upon the face. The vesicles of eczema are short 
lived and inflammatory. In adenoma of the sweat-glands the lesions 
are often painful and usually firmer and larger than in hydrocystoma. 

Treatment. — The lesions can be caused to disappear by puncturing 
each, thus permitting the escape of the imprisoned fluid. This should 
be followed by the application of dusting-powders, due care being had 
to avoid the effective causes of the malady. 

ANIDROSIS. 

(Gr. «, privative ; vdup, water. ) 

(Anhidrosis. Ger. and Fr., Anidrose.) 

This name is properly applied to those morbid conditions in which 
no sweat is secreted from the surface of the body. Hypohidrosis is a 
term more exactly used to designate a relative, general or partial de- 
crease in the quantity of the sudoral fluid. The former term, however, 
is often used to indicate the latter. 

Complete anidrosis occurs naturally only when the sudoral appa- 
ratus has been involved in destructive or other changes in the skin 
(scars, atrophy, etc.). 

Diminution in the quantity of sweat excreted, or its complete sup- 
pression, whether general or local, is a symptom of several disorders, 
but as a separate cutaneous affection it has no existence. This con- 
dition is common to many dermatoses, as, for example, ichthyosis, 
psoriasis, and some forms of eczema ; but in these the symptomatic 
character of the anomaly is illustrated by the fact that when the skin 
is relieved of these cutaneous troubles the function of sweat-secretion 
is restored. Similarly in neuralgias and certain forms of paralysis a 
circumscribed and temporary anidrosis may be the local expression of 
the nervous disturbance, precisely as in the case of the symmetrical 
hyperidroses. Lastly, there are individuals exhibiting the idiosyncrasy 
of either sweating not at all or quite imperceptibly in elevated tempera- 
tures, phenomena which should be ascribed rather to peculiarities in 
the equilibrium of the heat-exchanging factors than to congenital 
deficiency of the sweat-glands. 

Strauss and Bloch regard the occurrence of hypohidrosis and ani- 
drosis as differential diagnostic symptoms of diffuse myelitis, polio- 
myelitis, and cerebral paralysis. 

Treatment. — The measures capable of stimulating the sweat-secre- 
tion are : ingestion of water in quantity by the mouth, the external ap- 



BROMIDROSIS. 119 

plication of heat in a dry or moist atmosphere, and the use of jaborandi 
or pilocarpine by the mouth or by hypodermatic injection. In the 
anidrosis accompanying cutaneous disease the indication is always pri- 
marily for the relief of the latter. 



BROMIDROSIS. 

(Gr. ftptipoc, a stench ; vdup, water.) 

(Bromhidrosis, Osmidrosis, Fetid or Stinking Sweat. 
Ger., Stinkender Schweiss.) 

Symptoms. — In bromidrosis the perspiration is effused in such a 
state that it can immediately be perceived to possess an unusual odor, 
or, as Hebra taught was the case with the majority of patients, to be 
rapidly changed to that condition. It is often associated with hyperi- 
drosis, but may occur independently of the latter, and like the latter 
also be either general or localized. The odor may be either agreeable 
or disagreeable, having been in various cases compared to that of 
certain flowers and fruits as well as to that of several stench-emitting- 
animals. In this respect the sweat presents a striking analogy to the 
urine, with which it sustains a close and well-recognized physiological 
relation. 

General bromidrosis may be physiological, as in the case of indi- 
viduals of the African race, or in those with dark skins who are pro- 
fusely sweating during labor or in high temperatures. General patho- 
logical bromidrosis is rare. The odors emanating from the person in 
ulcerating syphilodermata, small-pox, malignant pemphigus, mycosis 
fungoVdes, and other disorders may, in certain cases, be associated with 
the sweat-secretion, but in other cases they doubtless are connected 
with the decomposition of pathological products of the inflammatory 
process. 

The local varieties of bromidrosis affect the regions in which the 
sweat is oftenest secreted in excess and its immediate evaporation pre- 
vented, as in the axilla?, the groins, the feet, the anogenital and the in- 
termammary and inframammary regions. In a qualitative sense every 
degree of odorousness is noted, from that which is merely slightly 
agreeable or offensive to the most intolerable stench. When com- 
plicated by a seborrhoea in situations where the parts are not only 
warm, moist, and covered by clothing, but also subjected to friction 
and remaining uncleansed, the most intolerable and nauseous fetor is 
perceived. 

Sweat may be effused in a normal condition upon and within the 
articles of clothing worn, and subsequently generate a stench by chem- 
ical changes both in the clothing and the fluid by which that clothing 
is saturated. This fact should never be forgotten in the practical 
management of any case. 

Etiology and Pathology. — Thin has recognized micro-organisms 
{Bacterium fwtidum) in sweat obtained from the feet. Parkes con- 
cludes that the only cause of the disease is the covering of the foot, 
as soldiers with uncovered feet do not suffer from this affection. It 



120 DISOEDERS OF THE GLANDS. 

is occasionally due to emotional causes, to chronic alcoholism, or to the 
gouty state. 

Treatment. — The treatment of bromidrosis is in general that of 
hyperidrosis already described. Formalin solutions in the strength 
of from 1 to 10 per cent, in alcohol are of the greatest value. They 
should be followed by the use of boric acid in powder externally. 
Thin l successfully employed stockings and cork-soles thoroughly dried 
after being saturated for hours in a jar containing a solution of boric 
acid. The efficacy of this measure he ascribes to the fact that the odor 
is the result of the development in the secretions of the Bacterium 
fwtidum. An ointment is also employed by him for similar purposes ; 
it is a solution of boric acid in glycerin incorporated with a fatty basis 
of white wax and almond-oil, making thus a "glycerated cream of 
boric acid." Armingaud, of the French Academy, has reported excel- 
lent results following the subcutaneous injection of 3 grains (0.20) 
of pilocarpine nitrate eight of which operations were successful in 
lessening the abnormal sweat-fetor. Clement Hawkins 2 finely tritu- 
rates 15 grains (1.) of red lead oxide, and to this adds gradually 
1 ounce (32.) of Goulard's extract. This preparation is used as a 
lotion following a nightly foot-bath containing 1 ounce (32.) of alum. 

Fox 3 advises a 1 per cent, solution of chloral or of potassium per- 
manganate as a topical application. 

Internally sodium salicylate has been employed with success in 
5-grain (0.33) doses. 

CHROMIDROSIS. 

(Gr. xpupa, color: vdop, water.) 

(Ephidrosis Tincta. Ger. and Fr., Chromidrose.) 

By this term is indicated the condition in which effused sweat 
exhibits an abnormal color — yellowish, reddish, greenish, or blackish. 
Cyanhidrosis is the term that has been employed to indicate blue 
sweating. 

In cases of chromidrosis there has usually been a copious secretion 
of fluid. Authors have variously attributed the color of the sweat to 
the presence of compounds of phosphorus, iron, cyanogen, indican, 
Prussian blue, hsematin, chromogen, and even to parasitic vegetations 
upon the skin-surface. Women, much more often than men, exhibit 
the free deposit of pigment upon the skin, and in view of the admitted 
rarity of chromidrosis the suspicion arises that in some of the cases 
reported there was free pigmentation of the surface, by which the fluid 
exuded was immediately stained or colored. Duhring reports a single 
case of red sweating in a vigorous male patient. Usually, however, the 
phenomenon occurs in persons who are debilitated and betray some evi- 
dence of impairment of other organs than the skin, thus furnishing an 
indication for treatment. 

Babesiu, 4 of Pesth, reports some interesting cases of this disorder 

1 Practitioner, December, 1881, p. 2101. 

2 Brit. Med. Jour., May 7, 1881. 
3 Loc. cit. 

4 Lancet, 1862. 



CHR OMIDR OSIS. ] 2 1 

in which the symptoms were due to the presence of bacteria, a fact 
confirmed by us in several instances. In eight patients, three of them 
women, there was considerable pruritus with pale-red to blood-red 
sweat ; in one of the patients the skin and hairs w r ere reddened. The 
axillae were the seat of this colored perspiration. In all the cases 
microscopical examination revealed similar changes. The hairs of 
the axillae were thin, pale red, brittle, and surrounded with a col- 
loid-looking, rusty, or bright-red sheath, in places of considerable 
thickness and having a rough surface. This sheath consisted of red 
masses presenting a radiating striation, more or less confluent, appar- 
ently proceeding from fibres of the cortex of the hair or from some 
broken part of its surface. The radiating striation was found to be 
due to the aggregation of round or ovoid bacteria (scarcely a micro- 
millimetre in diameter), which were united in zoogloea masses by a 
reddish intermediate substance. Nodular swellings on the hair were 
produced by the infiltration of the organism between the separated 
fibrils. The roots of the hair were free from bacteria. The red tint 
of the sweat was found to depend upon numerous roundish masses of 
zoogloea. 

T. C. Fox } reports also two cases of Cy anhidrosis in which a deep 
bluish-black pigment was exuded upon the skin of the circumorbital 
region. The amorphous granules were found insoluble in almost all 
hot or cold reagents, but they displayed a deep-blue color when moist- 
ened with glycerin, and a purplish hue when dissolved in hot sulphuric 
acid. 

Mitchell 2 describes an unusual case under the title of " Seborrhoea 
Nigricans," in which there was a dark greasy-looking discoloration 
of the eyelids and adjacent skin. 

The hypothesis, that certain cases described as chromidrosis are 
really instances of mechanical w T ashing of pigment to the surface in the 
profuse sweating of the debilitated, is strengthened by the phenomena 
of simultaneous hair-coloration. Thus, Prentiss 3 reports the case of a 
young woman, affected with acute cystitis and passing purulent urine, 
whose hair, under the influence of profuse sweating induced by the 
action of pilocarpine, changed speedily from a light blonde to a nearly 
jet-black hue. At the meeting in 1881 of the American Dermatolog- 
ical Association we exhibited hairs of a middle-aged man that had 
changed in a night from a grayish-white to a greenish and yellowish- 
brown hue. White, of Boston, has observed several similar cases of 
hair-coloration as the result of profuse sweats. In the year 1884 this 
observer reported to the Association the case of a workman in a sugar- 
refinery whose sweat from the left side of the body was of a bright- 
yellow color for several months. Though sought for, no bacteria were 
discovered. 

In a case observed by Bergmann a mycelium was recognized which 
w T as subsequently cultivated. Eberth has recognized bacteria in both 
normal and yellow sweat. 

1 Med. Press and Circ, Jan. 1, 1881. 

2 Phila. Med. Jour., Jan. 15, 1898. 

3 Phila. Med. Times, July 2, 1881. 



122 DISORDERS OF THE GLANDS. 

Le Hoy de Mericourt, first to name this disorder/ also 2 described a 
case of rosy sweating in an infant. 

Fereol believes that in these cases there is actually an absence of 
sweat, and prefers to call the disorder " chromocrinia." 

In all cases, before accepting statements of patients as to the exist- 
ence of symptoms of this character, it is needful to eliminate the possi- 
bilities of deceit and accident. Coloring-matters received upon the 
hands may be either wilfully or ignorantly transferred to the surface 
of the body. 

Greenish sweating, due to the presence of copper in the system, 
has been reported in a few instances. We have observed one case of 
this disorder in which the effect was produced by the copper plate of an 
electrode in contact with an abraded surface of the skin. 

Phosphorescent Sweating is reported to have occurred after the 
eating of phosphorescent fish and the ingestion of phosphorus for 
medicinal purposes. 

The Treatment of these several conditions is that of the general 
state of the patients exhibiting these symptoms. 

URIDROSIS. 

(Gr. ovpov, urine; vSop, water.) 

(Ger., Harnschweiss ; Fr., Uridrose.) 

Uridrosis is that condition in which some of the constituents of the 
urine, chiefly urea, are excreted in excess with the sweat. 

While a small amount of urea is to be recognized in normal sweat, 
this ingredient under peculiar conditions may be increased, and, together 
with urinary salts, be deposited upon the skin-surface after evaporation 
of the exuded fluid. Such symptoms have usually occurred either as the 
result of grave constitutional affections (such as cholera), or of organic 
renal diseases accompanied by anaemia, or of the ingestion of jaborandi. 
In a few cases the symptoms have been presented in individuals who 
were apparently in good health. The salts of the urine appeared upon 
the skins of these patients in the form of minute lamellae, or of a fine 
powder of whitish color and crystalline aspect. In some cases reported 
the symptoms have been noted to precede by a few days a fatal issue. 

The constantly adjusted equilibrium between the sweat- secretion and 
the urinary excretion would explain, for cases of a mild type, tem- 
porary augmentation in the urea found in the sweat of unusually free 
diaphoresis. Geber supposes that decomposition-products, such as 
ammonium carbonate, possibly in association with volatile fatty acids, 
may in part account for these conditions. 

In the effort to eliminate certain substances accidentally or pur- 
posely introduced into the system the sweat may possibly become 
charged with iodine, turpentine, tar, arsenic, and other substances. 
Several of the eruptions described in the chapter on Dermatitis Medica- 
mentosa are due to a similar eliminative effort, especially those accom- 

1 Arch. gen. He Med.. November, 1857. 

2 La France He'd., 1884. 



HTDRADENITIS SUPPURATIVA. 123 

panied by excessive sweating and the production of vesiculation. In 
the same manner it may be inferred that the sweat is at times charged 
with excrementitious and other products of the body ; as, for example, 
the elements of the bile. In patients affected w T ith yellow fever the 
skin and even the sweat which exudes from it often exhibit the char- 
acteristic hue of that disease. The so-called Galactidrosis, from 
supposed metastasis of milk, does not occur ; cases thus described have 
been instances of pathological sweat in the puerperal state. 

ELemattdrosis, or bloody sweat, reported as observed by several 
authors (Foot, Ebers, Parrot), is the name applied to conditions in which 
blood has been seen to exude from an unbroken skin. The phenomena 
described under this title belong properly to the ensemble of symp- 
toms called " hsernophilia," and may in some cases be due to direct 
transudation of red and white blood-corpuscles and fibrin into the inter- 
epithelial spaces traversed by the sweat-pores. Geber points to the 
neuralgic, hyperaesthetic, pruritic, or emotional symptoms that are usual 
precursors to the flow of pale or bright-red blood. The fact that 
patients thus affected are mostly women, hysterical, dysmenorrhoeic, 
or near the puberal epoch, also throws light upon these cases ; in many 
of them petechia?, or signs of hemorrhage into other tissues of the 
body, are observed. 

HYDRADENITIS SUPPURATIVA. 

(Hydradenitis Destruens Suppurativa ; Folliculitis Exul- 
cerans ; Spiradenitis Unna ; Acnitis Barthelemy ; Hy- 
dros adenitis Disseminata Suppurativa (Dubreutlh).) 

This disorder was described in 1864 by Verneuil, and since then 
has been observed by Dubreuilh, 1 Pollitzer, 2 and others. 

The lesions begin as deep-seated, firm, shot-like, uncolored, insensi- 
tive nodules over which the skin is movable and unaffected. Each 
nodule slowly enlarges for a week or longer until it attains the size of a 
pea and becomes soft, slightly painful, and attached to the skin, which 
is then reddened. On puncture the lesion gives exit to a drop or two 
of pus ; but if left to itself it becomes yellowish, bursts spontaneously, 
and becomes covered with a dirty adherent crust which soon falls, 
leaving a pigmented spot, and ultimately a slightly depressed scar. 

The most common sites of the disorder are the regions of the axillae, 
anus, nipples, scrotum, and labia majora. In these parts the lesions 
may be single or more numerous. They occur also in large numbers 
over other parts of the body, especially on the face, scalp, neck, but- 
tocks, and extremities. No cases have been reported with lesions on 
the soles. 

Occasionally several nodules coalesce to form a flat tumor with a 
number of openings ; or the small, firm lesions of the first stage may 
persist as such for months, terminating in absorption. The disease is 

1 Arch, de Med. exper. et d'Anat. pathol., 1893, i. 

2 Jour. Cutan. and Gen.-Urin. Dis., 1892, p. 9. Also, Morrow's System, vol. iii., 
p. 771. 



124 DISORDERS OF THE O LANDS. 

usually chronic in its course, and with successive lesions or crops of 
lesions may endure for months or years. 

Etiology and Pathology. — As predisposing causes should be 
counted all conditions, general or local, which tend to lower the 
vitality of the tissues. The origin is unknown, though it is probably 
to be sought in local infection or in the action of some toxic agent 
excreted by the coil-glands. 

The process has been shown to be a diffuse inflammation of the coil- 
glands and periglandular tissue, usually terminating in necrotic sup- 
puration and destruction of the gland. No micro-organisms have been 
recognized in the cases examined. 

Treatment. — The general condition of the patient should furnish 
the indications for the treatment of each case. Locally the nodules 
should be opened and dressed antiseptically. The disease is stub- 
born, but eventually terminates in recovery. 

Primarily the coil-epithelium undergoes changes which are respon- 
sible for the cellular infiltration of the peripheral tissue. 



2. DISORDERS OF THE SEBACEOUS GLANDS. 

SEBORRHEA. 

(Lat. sebum, tallow ; Gr. peu, to flow.) 

(Steatorrhea, Acne Sebacea, Dandruff, Seborrhagia, Seba- 
ceous Flux, Stearrhcea. Ger., Schmeerfluss ; Fr., Sebor- 

RHEE.) 

The clinical phenomena described under the title of seborrhoea are 
not due solely to a catarrh of the sebaceous glands, but result from 
several different pathological processes in which the coil-glands and 
epidermal layers are more or less involved. In the absence of suffi- 
cient knowledge of the pathology of these conditions they are in these 
pages considered chiefly from a clinical standpoint. The inflammatory 
processes in which the fat-producing glands seem to play an important 
part are described under the head of eczema seborrhoicum. 

Symptoms. — Seborrhoea occurs in two forms. According to the 
condition of the excreted product, they are described as seborrhoea 
sicca and seborrhoea oleosa. These two forms are recognized clinically 
as of separate occurrence, and also as existing occasionally at the same 
time in one person. Either form of the disease may be limited to 
certain sites of preference, or be generalized so as to extend over all 
portions of the body provided with sebaceous glands. The commonest 
seats of the disease are: the scalp, the face, the genital region, the 
dorsum of the body between the scapulae, and the anterior surface of 
the chest. It appears at all periods of life and in both sexes. As 
the sebaceous glands are mainly appendages of the hair- follicles, the 
lesions of the disease differ somewhat according as they exist in the 
regions covered with long or. with lanugo-hairs. For the same reason 
a difference marks the career of the disease. At times it is a trivial 
and short-lived affection ; at other times it is persistent and intractable, 



SEBORRHCEA. 125 

lasting for years and possibly for a lifetime. The individuals thus 
affected exhibit a difference also with respect to the condition of gen- 
eral health. Some are anaemic, chlorotic, or asthenic; some are of 
sanguine temperament, fleshy, red-faced, and thick-skinned; others 
again are absolutely healthy, so far as can be discovered, except for the 
local sebaceous disorder. The latter fact is of some significance. One 
may see extreme types of seborrhcea in vigorous men who have worn 
merely for one month a skull-cap to which was fastened an apparatus 
for relief of fracture of the lower jaw. The skin affected with a sebor- 
rhea is usually anaemic, and is either dry or humid. The subjective 
sensations are either slight and limited to a moderate degree of itching, 
of which the patient does not complain until he is questioned upon the 
subject, or these sensations are altogether wanting. At other times the 
glands or periglandular tissues are affected with a mild form of inflam- 
mation, and then the involved surface may be reddened and become 
the seat of a considerable pruritus. 

Seborrhcea Oleosa. — This form of seborrhoea, variously known as 
hyperidrosis oleosa (Brocq), seborrhoea simplex (Unna), stearrhoea sim- 
plex (Wilson), acn6 sebacee fluente, etc., is in its pronounced features 
rarer than seborrhoea sicca, but to a less degree it is a condition suffi- 
ciently common in many forms of the disease. The sebaceous secretion 
is exuded as an oily fluid upon the surface both of the hairy and so- 
called " non-hairy" parts of the skin. In the former situation, both in 
adults and infants, the free oily substance is seen to cover as a coating 
both skin and hairs, and, especially in bald adults, to produce a glisten- 
ing and shining appearance of the scalp. The secretion often concretes 
into masses, forming the crusts of seborrhoea sicca. The same greasy 
layer can be seen over the non-hairy portions of the skin, especially 
about the nose, forehead, and cheeks. Free drops of oil can occasion- 
ally be wiped from such surfaces with a handkerchief. The ducts of 
the sebaceous follicles here are either patulous or plugged with come- 
dones ; the skin-surface may be reddened or be pallid, but it is usually 
cold to the touch. The oily substance serves to entrap particles of dust, 
soot, etc., floating in the air; thus a peculiarly dirty or even blackish hue 
of the face is often produced. This form of seborrhoea, though most com- 
mon on the face and scalp, may occur on the chest, the back, the pubes, 
the genitals, and rarely on the other parts of the body. In the negro, 
in whom the sebaceous glands are usually well developed and active, 
the oily forms of seborrhoea are common, and the flux at times is practi- 
cally physiological. Even in the absence of their frequent anointing 
with palm-oil, one can see in Africa naked blacks whose skins shine 
from exuded grease. 

Subjective symptoms in seborrhoea oleosa are usually slight, though 
a moderate amount of itching is commonly present. On the scalp the 
disease often produces an alopecia which does not, as a rule, respond 
readily to treatment. 

Seborrhcea Sicca. — Seborrhoea sicca, as the term is generally accepted, 
varies greatly in its manifestations, but in general its features may be 
divided into the scaling and the crusting form of the disease. The scal- 
ing form, variously known as seborrhoea furfuracea or pityriasiformis, 



126 DISORDERS OF THE GLANDS. 

pityriasis simplex, eczema seborrhoicum, eczema squamosum, etc., is most 
common on the scalp, in which region it is popularly known as " dan- 
druff." Seborrhcea capitis in its commonest form is recognized in the 
adult by the formation on the scalp of fine, branny, slightly greasy, 
white or grayish scales, which may be so abundantly shed as to fall 
freely and cover the shoulders of the patient whenever the hair is 
brushed or otherwise disturbed. At other times these fatty scales are 
more or less adherent to the scalp-surface, or are piled up in laminae 
one upon another. These scales may mat the hairs to the scalp 
or be disseminated through the mass of the hair, some of the hairs 
penetrating a flattened greasy scale, as a twig might be passed through 
the centre of a leaf. In consequence of their deprivation of unguent 
the hairs to which the affected glands are accessory become dry and 
lustreless, and fall from their follicles. If the process be not arrested, 
atrophy of the hair-follicles ensues, the resulting alopecia becoming 
permanent. 

Fortunately, the seborrhcea is usually symmetrical, and, in like 
manner, the baldness which it occasions. The resulting disfigurement 
is of the character of symmetrical senile alopecia, which is chiefly 
annoying because of the premature loss of hair. When this loss is 
asymmetrical, which is decidedly exceptional, the disfigurement is 
greater. 

The affection may be circumscribed, and in conspicuously exhibited 
patches covered by thin, mealy, grayish or whitish scales ; or thick 
yellowish masses may paste the hairs firmly to the surface of the scalp. 
The disease may extend uniformly over the entire surface of the scalp, 
or, as is frequently noticed, may fringe the brow at the line of the 
hairs and then extend chiefly over the vertex, being conspicuous at the 
line where the hairs are parted from vertex to brow. 

Beneath the scales or crusts of dried sebum the scalp is usually 
lustreless and of a slate-gray color. As the disease does certainly at 
times exhibit intermediate between functional and inflammatory forms, 
the adjacent tissues may present a hypersemic or even an exudative 
feature, with true epithelial desquamation and considerable itching — 
alopecia pityroi'des, pityriasis simplex. One group of cases, assign- 
able to this class, deserves mention. In these cases there is a tol- 
erably well-diffused seborrhcea sicca of the scalp, and irregularly 
distributed over the surface are filbert-sized, generally circular, dark- 
reddish patches, covered with a moist secretion or a friable, gran- 
ular, reddish-yellow crust. These patches are scalp "excoriations" 
produced by the finger-nails. They are most common in " nervous" 
patients, who cannot resist forcibly digging the scalp on the slightest 
provocation. 

The eyebrows, the region covered by the beard, and the pubic hairs 
may be affected, although less frequently, in the manner described above. 
In the latter region the itching is often more severe than when the 
disorder is limited to the scalp. The disease not infrequently extends 
from the scalp to the adjacent portions of the face, neck, and ears. In 
these situations the skin is usually slightly reddened, while the scales 
are thin, adherent, and not verv abundant, These features may appear 



SEBORRHCEA. 127 

on the portions of the face more distant from the scalp, and on other 
parts of the body, in the form of dry, roughened patches which scale 
more or less, but which are only slightly, if at all, reddened. On such 
surfaces the condition may shade insensibly into those described under 
eczema seborrhoicum. 

The crusting forms of seborrhcea may occur on any of the hairy or 
non-hairy parts of the body, but are most common on the scalp and 
face. Occurring in infancy, the disease is known as " milk-crust," or 
as crusta lactea. This may merely be persistence of the dried vernix 
caseosa about the vertex in the newborn, or it may occur in scalps which 
have been perfectly cleansed after birth. The crust differs somewhat 
in color with the tint of the child's complexion, and may vary from a 
light yellow to a dark brown ; it may be thick, greasy, and mat the 
hairs ; or be thin, dry, and friable. This crust is a frequent compli- 
cation of the eczematous disorders of the scalp, and, as a consequence, 
every variety of hypersemia and inflammation may affect the tissue 
beneath the crust. In infants and children, however, the resulting 
alopecia is never permanent, as the rapidly growing follicles hasten 
to reproduce the hair. The disease is neither contagious nor followed 
by cicatrices, points upon which mothers are usually solicitous. The 
region of the brow, the surface covered by the beard of the male, and 
the pubic hairs may be involved in this type of the disease, though less 
frequently than in the furfuraceous form. 

The so-called " flower-leaf" type of seborrhcea (petaloides) is seen 
chiefly upon the anterior and posterior surface of the upper part of the 
trunk, especially over the sternum and between the shoulders. Here 
occur sharply defined patches slightly elevated at the margin, reddened 
in various shades, the color diminishing from periphery to centre. The 
resemblance to a flower-leaf is in many cases striking ; often a clover- 
leaf is suggested by three foliate patches united more or less distinctly 
at a common point. These features are more often encountered in men 
with a hairy chest, the faintly reddish patches gleaming between the thick 
and strong pilary filaments. In all these cases careful examination will 
reveal the seborrhoeic state of the patient either by discovery of a 
seborrhcea of the scalp, or of acne of the face, etc. 

On the face this form of seborrhcea is characterized chiefly by the 
accumulation of thick, dirty-yellowish, and even yellowish-black accu- 
mulations of sebaceous matter, often adherent to the surface and disfig- 
uring the features by the mask produced. This condition is conspic- 
uous about the nose, where the disease is at times symmetrically dis- 
posed. The crusts once removed, the skin beneath is generally found 
to be pallid or slightly reddened, with the orifices of the sebaceous 
ducts patulous ; while the under surface of the separated crust is seen 
to project downward in corresponding delicate prolongations compara- 
ble to stalactites. The crusts rapidly reform when the disease is not 
arrested. They are found in the furrows on either side of the nostrils, 
on the brows, the cheeks, and the pavilion of the pinna of the ear. 
They are most common at the puberal epoch in both sexes, when the 
sebaceous glands of the skin undoubtedly sympathize with the changes 
occurring: at the beo;inmncr of the sexual life, 



128 DISORDERS OF THE GLANDS. 

Seborrhoea may affect the eyelids, which are then reddened, slightly 
swollen, and in various degrees covered with minute crusts (less fre- 
quently with scales). The eyelashes often fall, and in cases of long 
standing their loss may be permanent owing to atrophy of the 
follicles. 

Seborrhoea of the umbilicus assumes special features, since the fatty 
matters in this region are remarkable for their tendency to speedy 
decomposition, with the production of an exceedingly fetid odor, which 
may prove to be the source of a mild grade of inflammation. In the 
latter event a reddish halo surrounds the umbilical depression, which 
may furnish a thin sero-purulent discharge. 

Seborrhoea of the genitals in men is usually located in the sulcus 
behind the corona glandis, though in individuals with a tight or a redun- 
dant prepuce it may be more extended. In women the accumulation 
occurs about the clitoris and vestibulum, though the external labia may 
be covered with the secretion in various degrees of fluidity. The 
smegma preputii supplied by the glands of Tyson may thus be the 
source of trouble either by its retention or its secretion in abnormal 
quantity or quality. In either event the tendency, as in umbilical 
seborrhoea, is to decomposition, fetid odor, and subsequent irritation, 
which may provoke inflammation of severe grade. The retention of 
this smegma beneath a tight or a redundant prepuce in men may be the 
cause of many reflex symptoms, such as incoordinated movements of 
the lower extremities, nocturnal enuresis and pollutions, hernia, and 
irritability of the testis. In some cases the secretion forms a ring (as 
hard as the rind of cheese) encircling the glans. It should be remem- 
bered that the young of both sexes as well as adults are liable to be 
thus affected, and that in young female children these symptoms may. 
have a medico-legal interest in connection with suspicion of criminal 
assault. 

Seborrhoea generalis, affecting the entire surface of the body, is an 
exceedingly rare disorder. In the infant (Sebokrhcea Squamosa 
Neonatorum, Ichthyosis Sebacea) the skin is universally spread 
with a greasy layer, which is rapidly renewed after removal, and 
beneath which the skin appears to be varnished in reddish-brown 
shades. The consequent stiffening of the' integument produces painful 
fissures, inability to take the nipple, and consequent marasmus. . 

In adults the disease may occur in marasmic subjects and in old 
people in the form of a persistent fine scaling on the trunk and extensor 
surfaces of the limbs, and is known as "Pityriasis Tabescentium." A 
yet rarer form is described by Kaposi under the name of "Cutis Tes- 
tacea," in which large portions of the skin, especially the extensor sur- 
faces of the limbs, are covered with greenish-brown or blackish crusts 
which are more or less broken up into plates. 

Etiology — Seborrhoea is probably parasitic in its direct origin, but 
may depend in part upon other conditions which act as predisposing 
causes. Many cases of seborrhoea occur in young male and female 
subjects affected with chlorosis or conditions analogous to that state. 
Other cases are essentially of local origin. A seborrhoea can be pro- 
duced artificially in a healthy individual in the course of a few weeks 



SEBORRHCEA. 129 

by simple local measures without interference with the general economy. 
Women with long hair are usually disposed to take special care of the 
scalp upon which it grows. Men with short hair attend chiefly to its 
disposition upon the head, and often neglect the care of the scalp. 
Such neglect is sufficient cause in some cases to produce seborrhoea 
sicca of this region. In certain types of the disease, and especially 
in those occurring on the non-hairy portions of the skin, chlorosis, 
struma, malnutrition, obstinate constipation, disorders of digestion and 
menstruation, and sedentary habits of life are present as predisposing 
causes. The sebum of individuals who have fatty livers from chronic 
alcoholism is peculiarly fluid and oily ; and few of the disorders of the 
sebaceous glands characterized by inspissation of the secretion occur in 
such persons. 

Seborrhoea oleosa is found more frequently in persons of dark com- 
plexion, while seborrhoea sicca is more common in blondes. A family 
tendency to furfuraceous seborrhoea of the scalp and a resulting alopecia 
may often be noted. 

Among the direct causes of this affection, as also of several other 
diseases of the sebaceous glands, may be named : the excessive use of 
tobacco ; the wearing of stiff, heavy, and ill-ventilated hats ; chronic 
alcoholism, gout, and syphilis. 

Pathology. — Seborrhoea oleosa in its simplest form is a hypersecre- 
tion of the fat-producing glands. That the oil-glands are active agents 
in this process is now accepted. 

Seborrhoea sicca has been supposed to be due to an abnormal func- 
tional activity and an imperfect fatty metamorphosis of the cells of 
the sebaceous glands. The fatty crusts, however, contain not only 
abnormal products of the fat-producing glands, but also exfoliated cells 
of the epidermis and hair-follicles. Most of the conditions described 
under seborrhoea sicca are primarily inflammatory and probably para- 
sitic in origin, and in some of the simple pityriasic forms the sebaceous 
glands are not involved. Furfuraceous seborrhoea may exist for years 
without clinical evidences of inflammation. 

According to Unna, alopecia precedes atrophy of the papillae, and 
in the early stages is due to a choking of the upper part of the hair- 
follicles with horny cells. The bed-hairs are thus loosened from the 
follicle and shed, while the lower part of the follicles, the papilla?, and 
the papillary hairs are intact. As the process continues the follicles 
are gradually dilated and filled with horny cells to a greater depth 
until the entire follicle, including the papilla, is atrophied and perma- 
nent alopecia results. 

Many of the clinical symptoms and pathological facts related to all 
forms of pure seborrhoea have a close connection with eczema sebor- 
rhoicum, the chapter devoted to which should be consulted in this 
connection. The efforts made by Unna to establish a morococcus as 
the effective agent in the production of this group of affections have 
not been successful. The microbacillus of Unna and Sabouraud appar- 
ently bears a very constant relation to seborrhoeal disorders, but its 
exact etiological position has not been determined. (See Alopecia 
Areata.) 

9 



130 DISORDERS OF THE GLANDS. 

Diagnosis. — Seborrhoea is to be distinguished from : 

Eczema. — The objective points of difference between eczema and 
seborrhoea depend upon the inflammatory character of eczema, upon 
the reddened, iufiltrated, or discharging skin, and upon the consider- 
able itching which it occasions. In squamous eczema the scales are 
rarely so abundant as to be shed freely from the surface, and are not 
greasy. It should be remembered, however, that the two diseases often 
coexist. Inflammation of those parts of the skin well supplied with 
sebaceous glands usually assumes one of the types described as eczema 
seborrhoicum. Eczema of the scalp in infants is frequently accom- 
panied by a seborrhoea, a fact which clearly shows that the technical 
distinctions between many diseases, useful though they be for analytical 
study, are not always capable of clinical demonstration. 

Ichthyosis. — This is a congenital disease, usually involving the en- 
tire surface of the body, while seborrhoea is generally acquired and is 
rarely universal. The distinction between ichthyosis and the rare gen- 
eralized forms of seborrhoea described above might involve a difficulty ; 
but in the latter the greasy character of the crusts, their color, and the 
marasmic condition of the subject would sufficiently distinguish the two 
disorders. 

Impetigo. — The only possibility of error in diagnosis would occur 
during the crusting stage of impetigo upon the scalp. But impetigo is 
an acute disease, with comparatively small, circumscribed, and isolated 
lesions, with crusts differing in character from the sebaceous matters 
formed in seborrhoea, and beneath such crusts the integument is red- 
dened and evidently the seat of an exudation. 

Lupus Erythematosus. — Lupus erythematosus, though occurring on 
the face, is rare on the scalp ; it is accompanied by characteristic 
changes in the structure of the skin, and is often followed by a scar. 
Its lesions are darker red than the congestive patches beneath certain 
seborrhoeas of the non-hairy parts. The scales of lupus are tenacious 
and dry, and require scraping for their removal ; those of seborrhoea 
are greasy and more readily detached. The contour of the seborrhoeic 
patch is ill-defined compared with that of lupus, which is very distinct, 
exception being made of the mask-like crusts seen in certain of the 
facial seborrhoeas, in which the greasy character of the layer is very 
evident. Hebra, in 1 845, described a " seborrhoea congestiva," which 
it would indeed be difficult to distinguish from lupus erythematosus, as 
the former is really an early stage of the latter. Typical cases of the 
two diseases are widely different and readily distinguished ; the atypical 
forms might lead to confusion. 

Psoriasis. — Psoriasis of the scalp may resemble seborrhoea sicca, but 
the latter is rarely developed in such a universal exanthem as is fre- 
quent in the former. There will come under observation few doubtful 
cases in which a psoriatic patch on an elbow, a knee, a leg, or over the 
sacrum will not point to the nature of the disease. The scales of 
psoriasis are lustrous, larger, and not greasy unless fatty applications 
have been made to soften them ; and, moreover, they cover a reddened 
and exuding patch of integument. Psoriasis of the scalp and face 
prefers the areas of the forehead adjacent to the hairs of the scalp, 



SEBORRHEA. 131 

and rarely departs boldly to the nose and the furrows beside the nos- 
trils — favorite sites of seborrhoea. In seborrhoea of the scalp the hairs 
are loosened and fall, a condition not present in psoriasis. 

Syphilis. — Some forms of the pustular syphilodermata located upon 
the scalp and face, if observed only in the stage of crusting, might be 
confounded with seborrhoea. Here the history of the case, the discov- 
ery of other signs of syphilis (adenopathy, mucous patches, etc.), and 
the character of the secretion and the surface beneath the crust, 
t )gether with the smaller size, more definite outline, and characteristic 
grouping of the lesions, should point to the identity of the disease. 
In syphilitic crusts about the angles of the nostrils there is often a 
peculiar reddish-brown tint of the skin at the edge of the patch, 
the so-called " copper " color, which is significant. Crusts of the 
hairy scalp in syphilis are very often accompanied by post-cervical 
adenopathy, and especially by indurated enlargement of the occipital 
glands. 

Tinea Circinata and Tinea Tonsurans. — In ringworm of the hairy 
parts, as also of the body, the microscopical discovery of the parasite 
will always point to the nature of the disease. Upon the scalp the 
affected patches are seldom so diffuse as in seborrhoea, are usually circu- 
lar, are often accompanied by fragility of the hairs, and in the latter 
case the discovery of stumps of hairs is significant. There are also a 
history of contagion and an absence of the greasy conditions of the 
scales characteristic of seborrhoea. 

Treatment. — The general and internal treatment of seborrhoea should 
be varied to meet the requirements of the individual case. The prep- 
arations most often indicated are : iron in anaemic young women, cathar- 
tics in sluggishness of the bowels, and cod-liver oil when there is impair- 
ment of nutrition. Duhring recommends calcium sulphide in doses of 
from t T q- (0.0066) to ^ (0.0133) of a grain. Arsenic, employed in the 
manner suggested by Sir Erasmus Wilson, is praised by Hebra : 

B Vin. ferri, f^j ss ; 45 

Syrup, simpl., ) - - f „•• . g 

Liq. potass, arsenit., j J ' 

Aq. destill., f gij ; 60 M. 

Sig. A teaspoonful to be taken three times daily with the meal. 

In many cases the acid iron mixture of Startin, or some modifica- 
tion of it, admirably meets the indications present : 



R 



Magnes. sulph., 


§ij; 


60 


Ferri sulphat., 


9ss-9j ; 


0.66-1 


Acid, sulph. dilut., 


f"3ij-f3iv; 


8-16 


Infus. quassiae, 


ad f^iv; 


120 



33 



M. 

Sig. A teaspoonful in water, to be taken through a tube after eating. 

The preparations of matzool, malt, and maltine, now largely em- 
ployed in the treatment of wasting diseases, will be found available in 
i cases in which cod-liver oil cannot be well taken. Lastly, the bitter 
tonics may be needed. Throughout the treatment the physician should 
insure a careful observance of the laws of hygiene. Sunlight, nutri- 



132 DISORDERS OF THE GLANDS. 

tious food, and open-air exercise are not to be disregarded. Many 
young women of indolent habits are greatly benefited by sending them 
daily to riding-schools for an hour's equitation. 

In cases in which it can be tolerated, daily cool salt-and-water 
sponging of the entire body-surface, followed by brisk friction, may 
be employed with advantage. The salt is added to the water in the 
strength of \ pound to the gallon. There is no advantage to be gained 
by using the preparations of " sea-salt " sold in the shops. The bath 
is omitted during the menstrual period in women, and in the case of 
delicate patients. It is, without question, the most valuable of hygienic 
measures in the management of the disease. 

The first indication to be met by local treatment in seborrhoea is the 
removal of the crusts and the fatty matters accumulated upon the 
surface. It is always well to warn patients, especially if the disorder 
be upon the scalp in an aggravated form and occur in young women 
with apparently luxuriant tresses, that a considerable loss of hair 
will result. Many of the hair-filaments are so impoverished by the 
disease and so loosened in their follicles that a complete cleansing 
of the scalp-surface will bring the hairs away in quantities sufficient to 
threaten speedy baldness ; and it is not rarely the case that patients 
attribute this to the treatment rather than to the disease. The fatty 
accumulations are first to be soaked with some oily fluid to facilitate 
their removal ; for this purpose olive-oil, cod-liver oil, vaselin, cold- 
cream salve, almond-oil, glycerin, or lard is usually employed. The 
substance selected should be used in quantity sufficient to permeate 
all crusts. It may be poured over or be rubbed into the scalp several 
times in the twenty-four hours, and at night a flannel or other cap 
should be worn. In the case of children and infants gentleness is 
required in thus treating the scalp, especially in the subsequent wash- 
ings, lest the surface be irritated. In young women it is rarely neces- 
sary to cut the hair. As soon as the soaking with oil is complete the 
crusts are to be removed by washing with soap and water, though when 
the accumulations are bulky, masses may be gently removed with the 
fingers or a comb. When the scalp is tender ordinary toilet or Sarg's 
glycerin soap may be applied with warm water ; but it is usual, in the 
case of adults, to employ the spiritus saponis alkalinus of Hebra — 2 
parts of green soap digested in 1 of alcohol, filtered, and flavored 
with lavender or bergamot. The surface should be thoroughly sponged 
with the spirit, and then warm water added until lather is abundantly 
produced over the scalp, when an excess of water is finally used to 
cleanse the part of crusts, oil, and soap. The scalp and hairs are then 
thoroughly dried and anointed with some bland, fatty substance if the 
exposed surface be tender and irritable ; if not, with some stimulating 
pomade or lotion. 

In cases in which milder effects are required the scalp may be washed 
with water containing such alkaline substances as borax, ammonia, or 
potassium carbonate. The popular prejudice against these articles is 
based upon the abuse of strong alkaline lotions in the hands of inex- 
perienced persons. Such lotions may readily be tested by the tongue 
before use upon the scalp. They should in all cases be followed by 



SEBORRHEA. 133 

an oily or greasy application medicated to meet the requirements of the 
case. 

The last-named precaution is an important one. However extensive 
the seborrheic crusts, it is possible to remove them completely in every 
case by the measures described above, and with the first treatment 
patients are often delighted. Their disappointment is correspondingly 
great when they discover that the seborrhcea is not at an end, and 
that in the course of a few days the fatty plates are as freely as ever 
deposited on the scalp, disseminated through the hairs, and showered 
upon the shoulders. Some will even declare that the soapy applications 
aggravate the disorder by increasing the seborrhcea. It should, there- 
fore, never be forgotten that, having disposed of the extraneous matters 
accumulated upon the surface, there is still to be remedied a functional 
disorder of the sebaceous glands of the part. 

In every case, then, after the use of soap and water, which may 
be repeated as often as need be, daily, at intervals of several days, 
or once a week, the scalp is to be thoroughly anointed. For this pur- 
pose olive-oil, cod-liver oil properly scented, almond-oil, vaselin, or 
glycerin and water may be used. Van Harlingen recommends, as a sub- 
stitute for other oils, the oleum sesami (oil of benne), since it does not 
dry and clog as do the former. An ounce (30.) of this oil rubbed up 
with 5 grains (0.33) of powdered benzoin, and digested for three hours 
over a water-bath, with the addition of 3 drops of absolute alcohol, 
and filtered, furnishes an excellent basis for oily mixtures to be used on 
the scalp. 

Morison 1 has devised an ingenious instrument for the application 
of oily lotions to the scalp. The fluid is contained in a small reser- 
voir, to which is connected a comb with perforated teeth ; through the 
latter the substance selected for medication of the scalp readily passes 
down to the surface between the hairs. A. medicine-dropper, though 
less convenient, will answer the same purpose. 

In the place of oils after these ablutions pomades are often used 
with more advantage. For this purpose vaselin, lanolin, lard, and the 
zinc-oleate ointment furnish the best bases. To obtain the desired 
consistency, any one of these may be used alone or in combination 
with the others or with an oil. 

Crocker advocates prior to the application of oily preparations to 
the scalp the use of a lotion containing acetic acid, the object being to 
aid the penetration of the remedy. 

Of the many remedies employed and recommended, resorcin, sul- 
phur, and the red oxide, bichloride, or ammonio-chloride of mercury are 
the most serviceable. Resorcin alone gives satisfactory results in the 
great majority of cases. This remedy may be used in a spirit lotion 
(from 25 to 75 per cent, of alcohol) in strength varying from 2 to 10 
per cent., or in the form of an ointment, 10 to 60 grains to the ounce 
(0.66-4. to 30.). Lotions are well adapted to cases in which ether 
is little inflammation and in which decided stimulation is required. 
As they are cleanly and easy of application, they are more pleasing to 
most patients, and especially to women with long hair. Their efficacy 

1 Maryland Med. Jour., January, 1885. 



134 



DISORDERS OF THE GLANDS. 



is often enhanced by the addition of a small amount of oil. Mercuric 
chloride is admirably adapted for use in lotions. A good formula is 
follows : 



as 



R Resorcin., 

Hydrarg. bichlorid., 

01. amygdal. dulc, 

Tinct. cantharid., 

Spts. vin. rect., 

Aq. destill., q. 

Sig. To be rubbed into the scalp. 



Sijss ; 


10 


gr- y ; 
3ij; 
3ij; 

Sy; 
s. ad f |jvj ; 


8 

8 

60 

180 



13 



M. 



For this may be substituted \ ounce (15.) of resorcin in 2 ounces 
(60.) of alcohol and 6 ounces (180.) of rose-water. 

Sulphur enjoys a high reputation in the treatment of all sebaceous 
gland disorders; in the form of an ointment, 15 grains (1.) to a 
drachm (4.) to the ounce (30.) of cold cream, it is often of service. 
One-half the quantity, or as much, of resorcin may often with advan- 
tage be added to the pomade. Sulphur may also be used as a powder, 
either alone or in combination with talc, salicylic acid, boric acid, 
starch, or camphor ; and as a lotion with alcohol, glycerin, and rose- 
or cologne-water. The alterative effect of the mercurials is also as 
evident in seborrhoea as in many other cutaneous disorders. At the 
head of the list, for this special purpose, stands the red mercuric oxide 
in strength of from 2 to 4 grains (0.133-0.266) to the ounce (30.) of 
ointment; but ammoniated mercury, and calomel in the proportion 
of from 5 to 10 grains (0.333-0.666) to the ounce (30.), may be often 
substituted for the former with advantage. Carbolic, salicylic, and 
boric acids, from 1 to 5 per cent, in alcoholic solutions, with or with- 
out the addition of oil or of glycerin, are often of service. The 
tars are useful in many obstinate cases. Tar-soap may be employed 
in the washing; or oleum rusci added in the strength of 1 to 10 parts 
to any of the salves recommended above. Ichthyol in ointments of 
the strength of from 5 to 10 per cent, has also proved efficacious. 
Besides these substances, tincture of cantharides, capsicum, and nux 
vomica are frequently incorporated with advantage into lotions and 
pomades for use upon the scalp. Most of the pomades can be rendered 
sufficiently fluent for use in this situation by adding 1 or 2 drachms 
(4.-8.) of glycerin to the ounce (30.) of lard or of cold cream. An 
excellent formula for the scalp is the following : 



R Sulphur, prsecipit., 
Lanolin., ] 

Glycerin., >• 

Aq. rosse, j 

Saponis, 

Sig. Ointment for scalp. 

Veiel recommends : 
R 



ffl; 

aa Sijss; 

Bss; 



4 
10 



Extra, cinchon. frig, par., £j ; 

Bals. Peruv., gtts. xv ; 

Cantharid. tinct., gtts. xxiv-gss ; 

Succ. citri, ^l xv ; 

Ung. pomat., ^jss ; 

Sig. To be rubbed into the scalp once or twice daily. 



1 

1 

1.5-2 

1 

45 



80 M. 



33 



M. 



SEBORRHCEA. 135 

Repeated applications and patient care of the scalp are necessary to 
secure complete relief in the case of a disease as essentially chronic as 
seborrhcea. At times the local treatment may be changed with advan- 
tage. Not infrequently too vigorous treatment is followed by a more 
or less acute dermatitis. In this case stimulating preparations should 
be replaced by soothing ointments or lotions until the induced inflam- 
mation has subsided. 

The treatment outlined above for the hairy portions may be used 
with success also for the relief of seborrhcea of the non-hairy portions 
of the body, especially the face. Here, it will be observed, the crusts 
have a tendency to re-form, and the most persistent treatment is nec- 
essary to secure permanent relief. Occasionally, after cleansing the 
surface with soap and spirit-lotions according to the indications of each 
case, it is of advantage to apply the ointment selected for subsequent 
application, not only by gently smearing it on the parts with the tips 
of the fingers (always the most effective method), but also by spreading 
it on a compress, which, for the night at least, may be fixed in contact 
with the part. Unna's lead-plaster mulls, used for this purpose in 
Germany, may fairly well be imitated by drawing strips of cheesecloth 
through heated diachylon ointment and then smoothly smearing them 
with the same material. When the tendency to re-formation of the 
crust is abated one or more of the dusting-powders may at times be 
employed with advantage for the purpose of protecting the skin or of 
exercising upon it an astringent effect. 

Seborrhcea oleosa is best treated with lotions or with powders. 
Should the skin become irritated under these applications, ointments 
may be substituted for a time. Astringent lotions or powders contain- 
ing tannin, gallic acid, zinc sulphate, ferrous sulphate, zinc oxide, 
bismuth subnitrate, etc., are often serviceable. 

The local treatment of seborrhoea of the genitals is somewhat differ- 
ent. Ointments rarely answer well in disorders of the mucous sur- 
faces, and green soap is too irritating for similar employment. Here 
washing with a good toilet-soap and warm water is sufficient for the 
purposes of cleanliness, and diluted lotions containing alcohol, in the 
form of whisky, brandy, or aromatic wine, suffice. These lotions can 
be made astringent with tannin, alum, or zinc sulphate, and when 
there is pain or tenderness opium may be added. In this form of the 
disease, as also in seborrhoea of the umbilicus, carbolic acid or chlori- 
nated soda may be necessary to correct fetor. After the employment 
of these lotions boric acid with talc (1 part to 4), or zinc oxide and 
starch (1 part to 8), may be dusted over the part. In the generalized 
varieties of the disease the surface is to be thoroughly anointed with 
oil. The body, especially that of infants, is to be swathed in flannel 
or other good non-conductor of heat, and a roborant treatment directed 
to the general adynamia. 

In the grave forms of seborrhcea of infants (described as keratosis 
sebacea, ichthyosis sebacea, etc.) the body must be kept anointed with 
oils or fats. Artificial feeding is demanded by the condition of the 
mouth. 

Prognosis. — In forming a prognosis in cases of seborrhoea of the 



136 DISORDERS OF THE GLANDS. 

scalp it must be remembered that the disease is frequently obstinate, 
and shows a decided tendency to recur unless some treatment be con- 
tinued for weeks or months after the scalp is apparently well. The 
resulting loss of hair, if symmetrical, may be remediless, but much 
may be done in the way of saving the hair which is left. Facial 
seborrhoea is much more amenable to treatment ; seborrhoea of the 
genitals and the umbilicus is an entirely manageable disease. When 
the affection is generalized the prognosis is in the highest degree un- 
favorable. 

ASTEATOSIS. 

(Gr. a, privative ; oreap, fat.) 

(Get: and Ft\, Asteatose.) 

Asteatosis is that condition of the skin in which there is absolute 
or relative deficiency of the sebaceous secretion. 

Symptoms. — Insufficient lubrication of the skin by its natural 
unguent may be either general or partial, and occur as an idiopathic 
or a symptomatic disorder. It is produced artificially by any agents 
which continually withdraw the fatty substance from the skin-surface, 
as in those trades necessitating the constant immersion of any part of 
the body in strong alkaline solutions or in waters strongly impregnated 
with calcium and potassium salts. As an idiopathic affection it is 
of rare occurrence, but it is not an infrequent accompaniment of 
other local or constitutional diseases, such as psoriasis, lepra, xeroderma 
pigmentosum, ichthyosis, and lichen ruber. In these cases the skin 
becomes dry, often thickened and indurated, and, as a consequence, 
friable, and prone to desquamation, fissures, and chaps. To the touch, 
the absence of sebaceous secretion is noticeable in the objective sensation 
produced. Asteatosis is a well-marked feature of the marasmus of old 
age. Some authors have described under this title the dry thickening 
and induration of the palm of the hand accompanied by curving of 
the fingers toward the plane of their flexor tendons, a condition that 
is occasionally to be observed in laundresses. 

Pathology. — In cases of asteatosis the lumen of the coil-gland is 
commonly dilated, the epithelium is swollen, the loops of the coil 
markedly thickened, and there is produced a compression of the inter- 
tubular connective tissue, as Unna has shown. 

Treatment. — No internal medicaments are known to have the power 
especially of stimulating the sebaceous secretion. None, indeed, could 
be capable of having such action when, as is often the case in the dis- 
orders characterized by asteatosis, there has resulted an atrophy of the 
sebaceous glands. For external application of an artificial unguent, 
cod-liver oil, almond-oil, lanolin, palm-oil, vaselin, lard, or butter may 
be employed. Vaselin is in many cases to be preferred, as the other 
articles named are liable to become rancid after oxidation, and thus act 
as irritants. Elliott prefers liquid albolene or benzol. With such 
partial or general lubrications, however, a warm bath of soap and 
water should be ordered every second or third day ; immediately 
after the bath the inunction may be repeated. 



COMEDO. 137 

Prognosis. — In all cases in which the asteatosis is induced by agents 
operating externally upon the surface a reasonable hope of recovery 
may be entertained after withdrawal of the cause. Persistence of the 
latter is liable to be succeeded by the occurrence of eczema or dermatitis 
medicamentosa. A complete cure can scarcely be expected when this 
condition is a symptom of one of the disorders already named. 



COMEDO. 

(Lat. comedo, spendthrift.) 

(Black-head. Ger., Mitesser ; Fr., Acne Poxctttee.) 

Symptoms. — Comedones, which occur exclusively in the ducts of 
the sebaceous glands, consist each of a whitish fatty plug formed by 
inspissation of the secretion of these glands, one extremity of the plug 
being visible at the surface when it is in situ. Occasionally the come- 
dones project to an appreciable distance above the general level of 
the integument, but often the extremity of each plug is slightly de- 
pressed below that level. There may be but two or three comedones 
upon the face, which is their commonest seat ; or the nose, forehead, 
cheeks, and chin, the front and back of the neck, the back of the 
trunk, and the penis may be studded with them thickly. The visible 
extremity of the comedo varies in size from that of a needle-point to 
that of a pinhead. Comedones are readily expressed from the follicles 
in which they are lodged, and when thus examined they are seen to be 
whitish moulds of inspissated sebum, one or two lines in length, the 
exposed extremity of each comedone having become blackened by 
diffused pigment deposited w T ithin. The popular idea that the black 
head of the comedo is produced by dirt entrapped by the sebaceous 
mass is without foundation. In consequence of this suggestive appear- 
ance of the lesion the disease has been called vulgarly " black-heads " 
and " skin-worms." The deformity produced in the face when these 
lesions exist there in large numbers is strikingly conspicuous, and 
it is for the relief of this appearance chiefly that the practitioner is 
consulted. The subjective symptoms awakened are of trifling moment. 
The disorder is essentially chronic in its course. Isolated comedones 
may be observed for years in one situation without apparent change or 
modification of any sort, and without producing the slightest local or 
constitutional derangement. Others appear, only to disappear under 
the influence of the usual hygienic regimen of the skin of the face. 
Others, again, serve to irritate the skin in which they are implanted, 
precisely as though they were foreign bodies ; and the sebaceous glands 
and periglandular tissues, with and without the operation of such cause, 
exhibit grades of hyperaeiiiia and inflammation. Comedones may 
occur as the sole lesions of the skin, even to the extent of great 
multiplicity ; or they may coexist with other diseases of the glands, 
chiefly acne. They may occur at any period of life, but, like seborrhoea, 
are most frequently observed at the puberal epoch in both sexes. The 
disease tends to disappear in women earlier than in men, in whose case 
it may be prolonged to the twentieth or thirtieth year. 



138 



DISORDERS OF THE GLANDS. 



Crocker l has called attention to the occurrence of comedones in chil- 
dren, with a special tendency to grouping in places subjected to heat 
and moisture, and also to their occurrence upon the hairy scalp. 

Occasionally a so-called "double" comedo is formed, there being- 
expressed from the skin a plug of inspissated sebum, each extremity of 
which is discolored. Whether this double comedo is due to a duplicity 
of efferent ducts in a single gland, or to an artificial or pathological 
connection between two adjacent glands, is not clear. 2 

Etiology. — Much has been written with reference to neglect of the 
skin as a cause of comedo, the non-employment of soap in washing 

Fig. 35. 




Section of a comedo : a, excretory duct of a sebaceous gland filled with a comedo ; it con- 
tains also two small hairs with brush-like inferior extremities ; into it opens a small hair- 
follicle (c) ; the contained hair (d), after touching the opposite wall of the duct, curves down- 
ward at /. (After Kaposi.) 

the face, and the influence of the trades, as in the case of those who 
work in metals, dust, and tar; but observation shows that these are 
exceptional causes. On the one hand, very obstinate and generalized 
lesions occur in the skin of intelligent young men and women of the 
upper social classes, who regularly wash their faces Avith toilet-soap, 
who are rarely exposed to dust, and whose habits and recreations are 
of the most healthful character. On the other hand, observing the 
grimy faces of coalheavers, machinists, masons, and ink-manufact- 

1 Lancet, April 19, 1884. 

2 Ohmann-Dumesnil : Jour. Cutan. and Ven. Dis., Feb., 1886. 



COMEDO. 139 

urers, one is impressed with the rarity of the disease in such laborers. 
Other causes of the constipation of the gland are unquestionably to 
be sought for in most cases. It is true that chlorotic young women, 
affected also with dyspepsia and torpor of the bowels, may exhibit the 
disease; and it is equally certain that many cases occur in peculiarly 
thick-skinned brunettes, or in men with a characteristic reddish-brown 
and greasy-looking complexion. Nevertheless, many such individuals 
never suffer from comedones, while often a perfectly healthy, fair- 
skinned girl will be greatly mortified by the disfigurement of her 
face. 

In yet other patients there is unmistakable connection between this 
disorder and chlorosis, scrofulosis, dyspepsia, habitual constipation of 
the bowels, menstrual derangements, and cachexia. This connection 
is demonstrated by the remarkable improvement manifested in the 
untreated skin when restoration of the general health is assured. 

The microbacillus of Unna and Sabouraud may be found, as a rule, 
in the comedo-plug, but whether the bacillus causes or follows the for- 
mation of the comedo is an unsettled question. 

Pathology. — The comedo is a dense collection of concentrically 
packed epithelial plates mingled with masses of cholesterin, with frag- 
ments of epithelia that have undergone fatty transformation, with mi- 
nute lanugo-hairs, and occasionally, upon the exterior, with the Acarus 
folliculorum. This mite, first detected by Henle in the ceruminous 
glands, was by Simon and others once believed to be the cause of the 
comedo, a view now abandoned. This parasite, in persons upon whose 
skin it exists, can be detected in masses of commingled sebum and epi- 
thelial plates scraped from the free surface of the integument, as also 
upon the skin-surfaces of those who do not exhibit any disorder of the 
sebaceous glands. 

The comedo-plug is located either in the excretory duct of the seba- 
ceous gland or in the pouch-shaped canal common to the sebaceous 
gland and the hair-follicle. It is divided by horny septa, and Avhen 
recent has a hollow "tail." The older and denser comedones have 
a horny extremity within the deeper part of the skin. It will be 
remembered that in the class of sebaceous glands chiefly involved 
in the comedo the hair-follicle is rather an appendage to the gland, 
the relation between the two, evident upon the scalp, for example, 
being here reversed. According to Biesiadecki, the hair-follicle in 
such cases often forms an obtuse or even a right angle to the duct 
of the gland, and the point of the hair being thus projected against the 
wall of the duct is occasionally curved downward upon itself, thus 
exciting irritation at the point of impact and subsequent multiplica- 
tion of the protoplasmic elements lining the canal. Thus he explains 
the epithelial character of the outer envelope of the plug; the special 
occurrence of the disease at the puberal epoch, when, as is well known, 
there is an especially active growth of the hairs; and, lastly, the fre- 
quent discovery of lanugo-filaments in the expressed contents of the 
common excretory duct. 

The blackness of the " head " is readily made to disappear when the 
extruded plug is treated with muriatic or nitric acid. It is to be 



140 DISORDERS OF THE GLANDS. 

noted that the pigment thus rendered soluble extends for some distance 
below the exterior face of the plug. 

Diagnosis. — The recognition of the disorder is attended with no 
difficulty, patients themselves being usually sufficiently observant to 
identify the affection, though frequently misled as to the character of 
the " skin-worm." It is, as might be expected, a frequent coincident 
of acne ; its lesions, when commingled with those of the disease last 
named, being either in preponderance or so infrequent as scarcely to 
attract the attention of the patient. A condition somewhat resembling 
comedo may be produced upon the face when tar or ointments of 
mercury and sulphur are applied to it at the same time, the resulting 
black sulphuret appearing conspicuously at various points upon the 
skin, often at the orifices of the sebaceous glands. 

Treatment. — The internal treatment of patients affected with 
comedo is that described in connection with the subject of sebor- 
rhea. Cod-liver oil, iron, the bitter tonics, and the medicaments in- 
dicated by any special condition of the patient's health are not to be 
omitted. Open-air exercise, daily cool salt-and-water bathing, as in 
the management of seborrhea, and the avoidance of all medicinal and 
dietary articles which might tend to aggravate the disorder, are also 
imperative. Many of these patients require at the outset alterative 
cathartics, among which may be named the pill of blue mass (taken for 
ten or more consecutive evenings, and followed by the effervescing 
sodium phosphate in the morning), calomel, cascara sagrada, and 
castor-oil. 

Even aggravated cases of comedo are completely relieved when 
untreated in the course of time. The relief, however, may require 
years for completion. The rarity of comedones in middle life and 
advanced years sufficiently attests this fact. Presumably this natural 
cure is due to more vigorous growth of lanugo-hairs with the increment 
of age, which thus push slowly forward to the surface the excrementi- 
tious mass, until it is gradually removed by ordinary friction and ablu- 
tion. Absence of comedones from the scalp, where the hair is vigorous, 
is certainly a significant fact. 

Comedones are removed artificially with the aid of an extractor. 
The instrument formerly employed for this purpose was shaped like a 
watch-key, the cylinder having a smooth bore and bevelled extremity. 
This clumsy tool is far surpassed by the exceedingly convenient com- 
edo-extractor designed by Unna and modified by Piffard. Each end has 
a convex bowl-like surface, with apertures cut to gauge and the orifices 
slightly countersunk. This extractor, " presser," is productive of far 
less pain to the patient than other instruments, and can be wielded, on 
account of its long shank, with greater precision and ease by the physi- 
cian. The surface to be operated upon is best previously moistened by 
spraying it with a solution of formalin (0.5 per cent.), of borolyptol, 
of thymol and glycerin, or of eucalyptol and glycerin. Often a sharp- 
edged or well-rounded needle, firmly held in a needle-holder, may 
advantageously be employed alternately with the extractor, in opening 
certain follicles or loosening the plug of others. Many patients affected 
with comedo are advantageously treated by the aid of the massering- 



COMEDO. 141 

ball, described in the chapter on the management of Acne. All these 
instruments should be disinfected scrupulously before use. The dan- 
ger of such manipulations should never be overlooked. There are good 
reasons for selecting the hour before sleep as the time for all vigorous 
topical applications to the face. Ointments then applied can be left in 
contact with the skin during the night, and the patient be at liberty to 
resume his usual vocation in the daytime, his face being free from con- 
spicuous evidence of local treatment. 

An ordinary watch-key, a curette, the thumb-nail, or a spatula may 
also, on occasion, be used in the extraction of comedones, w T hich, if 
few, may be expressed at one sitting, or, if numerous, be removed on 
separate occasions. Repetition of the process is usually required 
owing to re-formation of the plugs. 

Once the comedones are removed the skin should be sponged and 
bathed with hot water, then thoroughly dried, and anointed with an 
ointment which may be medicated to suit the indications of each case. 
Sulphur, as in all functional disorders of the sebaceous glands, en- 
joys here also the highest reputation. In the strength of 10 grains 
(0.66) to 1 drachm (4.) to the ounce (30.) of cold cream or vaselin, 
it may be applied as an ointment ; or as a lotion, in combination with 
spirit of wine, glycerin, etc. A useful application is suggested by 
Piifard — equal parts of sublimed sulphur, alcohol, compound tincture 
of lavender, glycerin, and camphor- water. 

Mercurials are also of some advantage locally, but, as before indi- 
cated, they should not be employed at the same time w T ith preparations 
of sulphur. The use at night, especially in obstinate cases, of the 
white-precipitate ointment, or of one compounded of 2 grains (0.133) 
of the red oxide to the ounce (30.) of cold-cream salve, will often prove 
of benefit. In the case of coarser skins, corrosive sublimate, 1 to 2 
grains (0.066 to 0.133) to the ounce (30.) of glycerin and rose-water, 
may be substituted for the red-oxide ointment. 

When extraction of the plug is not attempted nor permitted, some- 
thing may yet be done to remove the inspissated mass. Repeated 
sponging every third night with 1 ounce (30.) of green soap, digested 
in an equal quantity of cologne-water, will at first seem to render the 
comedo more conspicuous, but will slowly operate to dissolve the 
sebaceous secretion. 

An ointment containing 4 parts of kaolin, 3 of glycerin, and 2 
of acetic acid, with or without the addition of a small quantity of 
ethereal oil, may be applied at night for a few nights in succession, 
the eyes being carefully protected, when the black points of the lesions 
are removed, and the comedones are then readily extracted. Citric or 
dilute hydrochloric acid is employed with the same end in view. 
These topical remedies cannot be considered as efficient in every form 
of comedo. 

Actors, actresses, and women of fashion will, while under treatment, 
occasionally persist in using various colored toilet-powders, the inju- 
rious ingredients of which are often the cause of the disease. The 
practitioner may then either refuse to be responsible for the care of the 
case, may substitute a harmless for a noxious powder, or may gently 



142 DISORDERS OF THE GLANDS. 

anoint the face after his treatment of it with a bland ointment or the 
Lassar paste, upon the surface of which the theatrical effects are sub- 
sequently produced. In such cases the use of soap and water with each 
dressing is more than usually imperative. 

Comedones of the penis need not be treated. This injunction is 
suggested by the occasional demand made upon the physician by the 
sexual hypochondriac, who regards these lesions with a degree of alarm 
which he can best appreciate who has been confronted with a case of 
this kind. 

Prognosis. — As the disease naturally tends to spontaneous though 
occasionally long-deferred resolution, the prognosis is favorable. Treat- 
ment in most cases will accomplish much in hastening the disappear- 
ance of the comedones. The most obstinate forms are those in which 
the face, the back of the ears, the inside of the auricle, the neck, and 
the shoulders are studded with relatively small indolent comedo-points, 
about which the circular lip of the duct rises in a whitish rim. This 
rim, when felt with the finger, produces the impression of hyperplasia 
of the wall of the duct. Such cases, however, are nearly allied to the 
forms of acne described elsewhere. With exceeding rarity, the comedo 
is merely the introduction to a more serious local affection. In early life 
a single prominent lesion is formed, and though the plug be frequently 
removed and finally be no longer reproduced, the orifice of the duct 
remains patulous in middle life. Slowly thereafter its walls undergo a 
metamorphosis and a warty epithelioma may result. 

MILIUM. 

(Lat. milium, a millet-seed.) 

(Geutum, Strophulus Albidus, Acne Albida.) 

Symptoms. — Milia occur upon and about the eyelids, the cheeks, 
the temples ; the penis, scrotum, and corona glandis of men ; and the 
internal face of the labia minora of women. They are millet-seed- 
to pinhead-sized, globoid masses, rarely attaining the dimensions of a 
coffee-bean, showing within the epidermis as though kernels of rice 
were lying there immediately beneath a translucent layer of tissue. 
They occasionally project from the surface to such an extent as to 
resemble small-sized vesicles having milky contents. In color they 
are yellowish and whitish. They are often congenital, and can be 
recognized about the lids and temples of the newborn infant ; they are 
also seen, however, in middle life, when they develop very slowly, 
and sometimes persist for years. They are often observed in the 
neighborhood of cicatrices, which in such cases have usually been 
effective in their production. They occasion no subjective sensation, 
and are commonly so insignificant as to induce no deformity. They 
never degenerate by ulcerative processes, but when not artificially 
removed are, in the course of years, exfoliated in the natural processes 
of physiological desquamation. 

Etiology. — Milia are at times produced mechanically : the stroke 
of a knife-blade, accidentally or in the processes of surgery, separating 



MILIUM. 143 

one or more of the acini of a sebaceous gland from the main body. 
The contracting bands of a cicatrix, after destruction of tissue from 
any cause, may operate in a similar way with precisely the same result. 
They may occur in connection with acne, for which in many cases no 
cause can be found. 

Pathology. — When a milium is incised externally a spherical body 
of nearly corresponding size may be expressed, though it may require 
tearing from a minute pedicle below, which represents the attachment 
to the hair-follicle. The small mass thus extracted is seen to be a 
horny cyst composed of several thin envelopes, suggesting the capsules 
of the onion and representing cornified epithelia which have not under- 
gone fatty metamorphosis, and in the centre of which is a fatty nucleus. 
There is never any lobular formation. Each of these horny cysts is 
developed in connection with the lanugo hair-follicles, distending the 
latter, as Unna has shown, irregularly and on one side. The process 
represents a hyperkeratosis of the epithelium of the hair-follicles. 

The epithelia from which the contents of milia are produced at 
times tend to develop into horny or other formations. Thus, Foster, 
of Boston, describes a case in which the process of calcification had 
apparently been complete ; Wagner observed colloid contents in cer- 
tain opalescent lesions which appeared on the cheeks and temples of a 
woman ; Barensprung and Hebra report numbers of acutely produced 
milia following pemphigus and erysipelas ; and Virchow and Bind- 
fieisch describe milia of the hair-sacs and similar lesions accompanied 
by cysts of the adjacent hair-follicles. In some cases the cause of 
1 milia is to be sought in obscure changes by which the epithelia of the 
follicle are primarily affected. 

Robinson believes that milia originate from miscarried embryonic 

< epithelia from hair-follicles or from the mucous layer of the epidermis. 

Diagnosis. — Milia might be mistaken for minute vesicles containing 

, a milky fluid, but puncture of the lesion, with expulsion of its contents, 

at once discloses their character. Comedones with blackish external 

points, surrounded by the patulous orifice of the excretory duct and 

prolonged more deeply into the substance of the skin, could scarcely be 

confounded Avith milia. 

The most minute of the lesions of xanthoma have a yellowish color, and 
cannot as readily be scraped away from the subjacent tissue as can milia. 
Treatment, — Milia rarely require treatment, as they are usually 
• relatively few in number, and produce neither subjective sensation nor 
| deformity. If desired, they may be opened with a fine milium-needle 
| and their contents turned out, or they may be scraped off with a 
j curette. To insure their non-recurrence, the little sac left after the 
.operation may be entered with a needle which has been dipped in a 50 
per cent, solution of chromic acid. This operation may have to be re- 
peated in the rare cases in which the lesions exhibit a tendency to recur. 

The simplest and most elegant method of removing these and many 

similar-sized lesions of the skin is by the galvanic battery. With from 

'four to six cells in the circuit the negative pole is connected with a 

'fine needle, which is introduced within and beneath the lesion, while 

the moistened sponge of the positive pole is in contact with the skin of 



144 



DISORDERS OF THE GLANDS. 



the patient. This operation is bloodless and effectual, insignificant 
scars resulting. 

The Prognosis is always favorable. 

STEATOMA. 

(Gr. oreap, fat.) 

(Wen, Pseudo-atheroma, Sebaceous Cyst.) 

Symptoms. — The history of the development and career of wens 
does not greatly differ from that of milia, already described. Wens 
are usually of slow growth ; unattended by subjective sensation ; occur 
as single or multiple, fixed or movable tumors on the head, the trunk, 
or the genitals ; and, being larger than milia, may attain the size of a 
hen's egg. Centrally or laterally placed is usually seen on the surface 
of each a patulous orifice closed with a blackened horny plug suggesting 
a giant-comedo. They are situated beneath, within, or upon the skin ; 
are usually unattached to the deeper contiguous tissues ; and develop 
into irregularly globular, occasionally large button-shaped masses, 
covered by an integument usually unprovided with hairs. This 
envelope may be normal in hue, or unnaturally whitish from pressure ; 
or, especially upon the bald scalp of certain fleshy men of middle 
years, reddened, shining, and greasy in appearance. Their semisolid 
cheesy and milky contents often emit a nauseous odor. At times the 
cysts are to be distinguished only by passing the fingers through the 
long hairs of the scalp beneath which they are hidden ; at other times 
they are so conspicuous in consequence of physiological alopecia as to 
occasion considerable disfigurement. They vary greatly in consistency, 

but usually produce to the touch a cer- 
tain feeling of elasticity, especially if 
the cyst be tensely distended. They 
are rarely attacked by inflammation, 
resulting in suppuration and ulceration. 
Tumors of this kind may be exceed- 
ingly numerous. MacLaren's patient, 1 
a lad nineteen years old, exhibited 
tumors over the entire surface of the 
body ; they proved on examination to 
be sebaceous cysts, but they presented 
all the appearances of multiple fibro- 
mata. 

Pathology. — Wens represent dis- 
tention of the sebaceous glands by their 
contents, and response to the constant 
pressure in hypertrophy of the gland- 
ular envelope. Their contents, which 
are semisolid, curdy, cheesy, and gran- 
ular, fluid and milky, or fluid and 
purulent, are the inspissated or chemi- 
cally altered products of the gland-secretion, recognizable as such .by 



Fig. 36. 




Cysts of the scalp, one of them being 
laid open to show its contents. (Gross.) 



1 Brit. Med. Jour., Oct., 1886. 



STEATOMA. 145 

the materials of which they are composed — masses of fat and debris of 
epithelia, with an occasional lanugo- or undeveloped hair. 

In some cases wens are more than mere retention-cysts, a benign 
new-growth of connective tissue forming the mass of the tumor. Cal- 
careous and atheromatous changes in the contents of the cyst are 
common. Torok, Chiari, and others claim that the majority of these 
growths are really dermoid cysts. Torok found a true papillary body 
in the walls of many of these cysts, and states, furthermore, that such 
cysts contained no fat. 

Diagnosis. — Steatomata are to be distinguished from true athero- 
mata by observing that the latter exhibit no opening, never have 
odorous contents, always originate in the hypoderm, and frequently 
occur in portions of the skin other than the scalp. Steatomata are 
also to be distinguished from fatty tumors, which, however, are more 
commonly observed about the scapulae, loins, buttocks, and extremities ; 
while wens are very rarely found except about the scalp and neck ; 
they lack also the peculiar "pillowy 7 ' feel of fatty tumors. Suppurat- 
ing wens in the regions named may readily be mistaken for circum- 
scribed abscesses if regard be not had for the history of the tumor 
usually long preceding. Syphilitic nodes of the same parts are usually 
both tender and painful ; osteomata are also firmly attached. 

Treatment. — The removal of a wen is accomplished by excision, 
after previous puncture of the sac and removal of its contents. 

With antiseptic precautions ablation of these lesions from any 
part of the body may be regarded as unattended with great risk. 
Several fatal cases, however, are on record as the result of this opera- 
tion, due not so much to the nature of the excised tumor as to its 
situation, surgical wounds of the scalp being particularly liable to 
erysipelatous and other complications. As the incision required for 
the removal of the wen must necessarily extend some distance on 
either side of the tumor, there results a linear scar, which on the bald 
scalp is often a very conspicuous relic of the lesion. In consequence 
of the possibility of danger many surgeons prefer destruction of a 
prominent section of the mass with acid or alkali, leaving the sac, after 
expulsion of its contents, to wither gradually, though it may then be 
often withdrawn with forceps. 

Complete obliteration is sometimes effected by puncture, expression 
of the contents, and subsequent induction of artificial inflammation in the 
walls of the cyst by injection of tincture of iodine, pure sulphuric ether, 
or other irritating fluid, as in the operation for relief of hydrocele. 

Prognosis. — The removal of the wall of the cyst is not followed by 
a return of the lesion. In debilitated and cachectic patients there may 
be spontaneous ulceration and sloughing, with or without surgical in- 
terference. Mr. Thomas Bryant 1 reports a carcinomatous tumor 
following the removal of a steatoma from the buttock of a woman 
sixty-three years of age. 

Congenital Fibrosebaceous Disease. — Crocker reports two 
instances occurring in infants who at birth exhibited signs of the 

1 Brit. Med. Jour., May 13, 1884. 
10 



146 DISORDERS OF THE GLANDS. 

disease, in which patches with an area of "several square inches" were 
visible on the face, the front of the neck, and in front of and above 
the ear. These patches were slightly raised, of a pale reddish-yellow 
color, finely granular over the surface, and consisted of closely aggre- 
gated, pale-yellowish, pin-point-sized papules, the patches being sharply 
defined with many comedones at the borders. These growths, on sec- 
tion, seemed to be due to a fibrous hypertrophy resulting in atrophy 
of the hair-follicles and coil-glands, and separation of the lobes of the 
sebaceous glands. 

Painless Dermoid Cysts. — These occur, either as single, few, 
or more often as exceedingly numerous, un colored or yellowish- 
white pinhead- to small nut-sized lesions, strongly resembling multi- 
ple fibromata, but all containing a sebaceous or cheese-like matter 
when incised and the contents expressed. They are subcutaneous in 
situation, and like atheromata exhibit no opening. They occur chiefly 
about the nose and over the temples. Jamieson, Hebra, Rayer, Pol- 
litzer, 1 and others have reported cases, the last-named observer finding 
a well-defined cyst- wall with cystic contents consisting of typical epi- 
thelium transformed into horny cells undergoing fatty degeneration. 
Pathologically they are recognized as embryonal cysts of tardy evolu- 
tion. In different cases they are found to contain horny masses, bones, 
teeth, wisps of hair, cartilage, and a turbid fluid. 

Rare Consequences of Sebaceous Cystic Disease are reported 
by Cook, Hutchinson, and others, in cases in which steatomata in 
typical situations resulted in ulcerations of malignant type ; in still 
other cases fungous tumors of considerable size formed, requiring surg- 
ical attention. 

1 Jour. Cutan. and Gen.-Urin. Dis., Aug., 1891. 



CLASS II. 
INFLAMMATIONS. 



EXANTHEMATA. 

(Gr. e^dvdTj/ia, blossoming, flowering.) 

For a detailed consideration of the phenomena of the exanthematous 
fevers the reader is referred to the standard treatises on the subject 
in the field of general medicine. Space is allotted here merely to a 
description of the cutaneous lesions by which they are severally char- 
acterized. These are unlike in each disease, yet all exhibit certain 
common characteristics. In all the eruptions are symmetrical, and in 
typical cases are general. In each the efflorescence is succeeded by a 
desquamative or exfoliating condition of the skin. In each there is, 
within relatively fixed limits, a distinct stadium of the pathological 
process within which it is completed, and beyond which, however per- 
sistent may be its remote sequelae, there is no chronic manifestation 
of the disorder. Each, also, is produced solely by its specific con- 
tagium, derived exclusively from an animal body affected with the same 
disease, being never, so far as known, generated from any other source, 
nor merging by imperceptible degrees the one into another. Two of 
these may rarely concur, but under such circumstances the one is 
always more pronounced in its features, which either closely precede or 
follow those of another. No specific medication is known to be capable 
of arresting any one of them, each pursuing its course uninterruptedly 
to a favorable or a fatal termination, according to the intensity of the 
poison present in each case and to the more or less favorable or unfavor- 
able conditions of the sufferer. Finally, it seems probable that at no 
distant date specific bacteria or micrococci will be demonstrated to be 
etiological factors in the production of each. 

MORBILLI. 

(Measles, Rubeola. Ger., Maseru; Fr., Eougeole.) 

This disease is preceded by a period of incubation lasting from eight 
to twenty-one (usually between twelve and fifteen) days, a period in 

1 which there may be no evidence of ill health, or merely a moderate 
degree of lassitude and inappetence. To this period succeeds a pro- 

/ dromic fever, the temperature rising to 103°-104° F., occasionally 
alternating with chills or a sensation of chilliness, dryness of the skin, 
pains in the head, thirst, occasionally sweating, rarely convulsions in 

147 



148 INFLAMMATIONS. 

children, and almost invariably a serous catarrh of the mucous sur- 
faces, with specially pronounced ocular, nasal, pharyngeal, and laryn- 
geal phenomena. By the second or third day the temperature begins 
to decline, while the catarrhal symptoms increase, these being mani- 
fested in sneezing, a copious secretion from the eyes and nose, and 
engorgement of the exposed mucous surfaces, especially of the conjunc- 
tivae, the nares, and the throat. Occasionally the tongue and the fauces 
exhibit a few closely set, isolated, minute reddish puncta (enanthem). 
In consequence of the implication of the larynx, the trachea, and ulti- 
mately the larger bronchi, there is a hoarse, frequently an incessant 
and teasing cough of a convulsive character, accompanied by expectora- 
tion of mucus and muco-pus in moderate quantity. This prodromic 
period lasts from three to five days, but in exceptional cases is pro- 
longed to twice that length of time. Upon its conclusion the exanthem 
appears, usually on the fourth day, with aggravation of the fever, the 
temperature rising to 104°-106° F., and remaining at that point until 
the eruption has reached its apogee, when it commonly declines pari 
passu with the severity of the skin-symptoms. 

Koplik's 1 diagnostic early sign of measles is the development on 
the mucous membrane of the lips and cheeks of children, often as early 
as seventy-two hours before the appearance of a characteristic exanthem, 
of bluish-white spots or of brilliantly red patches with a bluish-white 
punctum centrally situated in each. The occurrence of this early sign 
of the disease has been corroborated by many observers. 

The eruption of measles usually appears first upon the face (the 
forehead and temples), and thence extends in about thirty hours over 
the neck, the upper portion of the trunk, and the superior extremities. 
Between the fourth and the sixth day of the disease it usually attains 
its deepest shades of color and its maximum of development over the 
entire surface of the body, including the palms and the soles. This 
maximum attained, the eruption gradually fades; the tumid condition 
of the skin, most noticeable on the face, also subsides; the catarrhal 
symptoms and cough become less annoying; and the patient enters 
upon the period of desquamation. 

The eruption is almost invariably symmetrical, and is characterized 
by the occurrence of a diffuse reddish, yellowish-red, mulberry-red, 
deep raspberry-red, or, in extreme cases, violaceous-tinted coloration 
of the skin, or of pea- to small finger-nail-sized fairly well-defined 
macules, either not elevated or very slightly raised above the general 
level of the integument; or by the occurrence of large pinhead-sized, 
discrete papules, much more rarely pin-point-sized vesicles, correspond- 
ing in color with the shades described above, and highly suggestive of 
the first efflorescence in variola. These lesions become pale under 
pressure, exhibiting then a yellowish tint, and are often set together 
closely, particularly over the upper segment of the body, in patches 
suggesting a crescentic outline. The term " suggesting" is here used 
purposely, as it is difficult, by selecting a single patch, to determine by 
the eye alone the existence of such a configuration ; while an examina- 
tion of the eruption as a whole may often very clearly convey this 

1 Arch, of Psediat. ? December, 1896 ; N. Y. Med. Kecord, April 9, 1898, 



MORBILLI. 149 

impression to the sight. Usually, patches of sound skin can be recog- 
nized even when the eruption appears to be confluent, complete con- 
fluence never occurring so as to form a sheet or mask over the entire 
skin-surface. Individual lesions may so merge as to be well-nigh 
indistinguishable separately; yet, on the wdiole, the eruption deserves 
fully the plural character of its English name. It is made up in all 
cases of innumerable elements, whose identity is never wholly lost. 
The subjective sensation awakened is occasionally a severe itching or 
burning; frequently this is an insignificant matter compared with other 
disagreeable symptoms — the cough, coryza, and fever. 

The exanthem spreads from the face to the upper extremities on the 
second day, and over the lower limbs on the third day of the rash. Its 
complex expression usually coincides with decided aggravation of the 
catarrhal symptoms. 

Desquamation is accomplished usually with cessation of fever and 
the production of delicate yellowish-brown pigmentations of the surface 
where the elements of the eruption have existed, involution being first 
manifested in the site of the lesions which were earliest to develop. 
Gradually and simultaneously the catarrhal symptoms of the respiratory 
passages diminish in severity. This final stage of the disease is usually 
terminated in a fortnight from the date of invasion. 

The complications and anomalies of measles depend upon the intens- 
ity of the poison, displayed in the most formidable symptoms where 
human beings are crowded together, as in camps and prisons ; upon 
the degree of physical vigor ; and also upon the various hygienic sur- 
roundings of the victims of the disease. Thus, the period of efflores- 
cence may be unusually prolonged ; the eruption may disappear 
suddenly, and as rapidly reappear; the cutaneous symptoms may alone 
be wanting ; the latter may be commingled with petechia due to 
cutaneous extravasation of blood, which may also be accompanied by 
severe epistaxis ; and the catarrhal condition of the mucous surfaces 
affected may terminate in croupal or in diphtheritic disease, may be 
followed by capillary bronchitis, catarrhal pneumonia, and even by 
pulmonary tuberculosis. Typhoid conditions may also supervene, and 
chronic inflammatory affections of the eyes and of the Schneiderian 
membrane result. 

The Pathology of the cutaneous lesions in measles is that merely 
of acute hyperaernia occasionally passing into exudation, limited for the 
most part to the vascular papillae of the corium and the perifollicular 
plexuses of blood-vessels. There is oedema of the fatty tissue surround- 
ing the coil-glands, in the sheaths of the larger vessels, the cutaneous 
muscles, and the hair-follicles. The coils, follicles, and muscles seem 
to swim free in widely dilated spaces. There is no cellular exudation 
and no mitosis (Unna). Post mortem the eruption fades, as the result 
of gravitation of the blood from the anterior aspect of the body as it 
reclines upon the dorsum. 

While it is possible that the etiology of measles will be based upon 
discovery of micro-organisms, no observer can claim to have con- 
clusively established this fact. Bacteria of small size and remark- 
able motility have been found in the blood by Coze and Feltz ; micro- 



150 INFLAMMATIONS. 

cocci in the trachea by Klebs ; spherical bodies in the breath of chil- 
dren, and post mortem in the lungs and liver by Braidwood and 
Vacher ; and similar organisms in the vesicles and pustules of malig- 
nant measles by Keating and Formad. 1 

The disease is chiefly one of infancy, probably because at that age 
there is always the largest number of individuals unprotected by pre- 
vious attacks. In every case the malady results from contagion, medi- 
ate or immediate, from an infected human subject. It spares neither 
age nor sex, though it is much rarer in advanced years than at other 
periods of life, probably because of the large number who at such 
period enjoy immunity. 

The Diagnosis of importance is between scarlatina and variola. 
Typical cases with a well-developed eruption can scarcely be mistaken 
for either if the symptoms displayed are assigned their full weight. 
It would be useless, however, to deny the fact that there occur atypical 
forms which have again and again confused the most expert diagnos- 
ticians ; in all cases of doubt the prudent practitioner will refuse to 
decide as to the nature of the disease until the symptoms have, in the 
lapse of time, fully been declared. The resemblance between ill- 
developed measles and certain of the eruptions seen in varioloid is in 
the highest degree striking, and the greatest skill, at a given moment of 
time, will in cases utterly fail to make a decision between the two. A 
distinctly crescentic character of the eruption, the presence of catarrhal 
symptoms, the continuance of fever alter the efflorescence is com- 
pleted, the color of the eruption, and the discovery of the nature of 
the disease from which the contagion was derived, will all point in the 
direction of the truth. From scarlatina measles is much more readily 
differentiated by the macular or papular elements of its eruption ; by 
their color ; by their appearance to a marked degree upon the face ; 
and by the absence of the characteristic sore throat and usually intense 
febrile access of the first-named disease. From the various forms of 
erythema accompanied by fever, measles can always be distinguished 
by the irregular temperature-record as well as by the character of 
the eruption. The diagnosis between rubeola and rothlen is given 
later. 

The Treatment of measles should strictly be limited to careful 
hygienic attention to the invalid, including a restricted " fever diet," 
and the use of only such medicaments as are especially indicated. 
The antithermic remedies employed in the general management of the 
febrile process may be required in special cases. 

In the way of local treatment the skin should be anointed with a 
bland, oily, or fatty substance, to relieve the pruritic sensations, espe- 
cially after sponging of the surface once daily with a weak alkaline 
solution, which may be used cool without fear of producing " reper- 
cussion " of the exanthem. The chamber of the invalid should be 

1 Canon and Pielicke have recognized bacilli in fourteen instances in the blood, as 
also in secretions from the nose and conjunctivas, and in lung-tissue after death from 
measles. These organisms were cultivated with marked success in bouillon. Czajowski 
cultivated a long, slender bacillus with blunt ends in nineteen cases; while Dohle de- 
scribes flagellated protoplasmic bodies found by him in the blood, and supposed to be 
etiologically effective. Sternberg's Magnan's Bacteria. New York, 1884. 



ROTHELK 151 

somewhat darkened for the sake of the eyes, but pure air should con- 
stantly be admitted. 

The Prognosis is in general favorable, but is of the gravest in special 
conditions. All the complications named above increase the gravity 
of the disease, which is also enhanced' among men crowded together in 
camps, children in public charities, pregnant women, the cachectic and 
those greatly enfeebled from disease, very young infants, old men and 
women, and residents of islands that have been long unvisited by epi- 
demics of the malady. 

The disease has been demonstrated to produce itself by contagion 
two to four days before the appearance of the rash, while the capability 
of transmission is usually lost between the twentieth and the thirtieth 
day after the exanthem is fully developed. 



ROTHELN. 

(Rubeola, Rubeola Notha, Rubella, German Measles, Hy- 
brid Measles, French Measles, Epidemic Roseola. Fr., 
Rubeole.) 

Symptoms. — This disease has an incubative period lasting from 
fourteen to twenty-one days, followed either by the eruption or by 
short-lived prodromes lasting for a few hours to a single day. These 
symptoms are malaise, cephalalgia, articular pains, anorexia, and 
nausea. The occipital, cervical, and other glands may at this time 
become large and tender. After a pyrexic period, rarely lasting 
longer than a few hours and in many cases absent, the eruption ap- 
pears, occurring for the most part in the regions affected by measles, 
in the form of multiple, pin-point- to small pinhead-sized macules, 
but smaller than the lesions displayed in that disease, and decidedly 
lighter in color. The shade is from a rosy or pinkish to a crimson 
red, rarely lurid, never of dark mulberry or violaceous hue. This color 
at times will be perceptible beyond the line of the lesions as a deli- 
cate halo, a circumstance which strongly distinguishes the exanthem 
from morbilli. The lesions, moreover, are seldom arranged in cres- 
centic outline, being more often grouped in roundish or oval patches. 
Often, indeed, the elements of the eruption are discrete and dissemin- 
ated. The fauces are occasionally reddened in puncta. The eruption 
commonly fades in from a few hours to one to two days, and there may 
be slight resulting cutaneous desquamation. 

The rash of rotheln is to be distinguished from that of measles by 
the recognition of the features described above, particularly by the 
color, contour, and date of occurrence of the exanthem ; the transitory 
character of the fever when the latter is present ; the cervical adenop- 
athy ; and the rapidity with which involution of the disease progresses. 
By the temperature-record alone of the patient it may be differenti- 
ated from scarlatina, though the rashes are dissimilar in the two dis- 
eases. It is also not to be confounded with the erythematous affec- 
tions of the skin. One of the most striking characteristics of the disease 
can be best recognized in a ward filled with children, all of whom are 



152 INFLAMMATIONS. 

simultaneously affected with the disorder. That characteristic is the 
remarkable mildness of the phenomena displayed in every case. 

While the symptoms of roth el n are so defined as to justify a reason- 
able certainty in its diagnosis, it is now generally accepted that the 
malady exhibits no characteristics that may not be often assumed by 
measles. Further, by some observers the identity of the affection, as 
distinguished from all others, has been called in question. 

Treatment.— Kotheln should be treated by rest in bed, an abundant 
supply of fresh air, strict asepsis, and the usual diet of fever-patients. 
Medication by drugs is rarely indicated. 

SCARLATINA. 

(Scarlet Fever, Scarlet Eash, Canker Rash. 
Ger., Scharlach; F?\, Scarlatine.) 

The period of incubation of scarlet fever varies between twenty-four 
hours and six days, the average duration being about three days. The 
reason of this variation is to be sought, not in any changeability in the 
mode of evolution of the disease, but in the fact that its poison is less 
volatile and less rapidly dissipated than is that of measles, the result 
being that it may remain potential for longer periods in connection with 
articles through the medium of which it is transferred from one indi- 
vidual to another. This incubative period, like that described in con- 
nection with measles, may be unproductive of physical symptoms, or 
may be associated Avith ill-defined malaise. 

Symptoms — The prodromes of the disease in typical cases are 
marked by the occurrence of a rapid and bounding pulse, an exceedingly 
dry skin, vomiting, headache, and a characteristic sore-throat. When 
examination of the mouth is made the tongue is seen to be thickly coated, 
and its filiform papillae reddened and prominent, features of the 
so-called " strawberry-tongue. ,; The velum, the pillars of the fauces, 
the tonsils, and all exposed mucous surfaces are engorged, tumid, red- 
dened, and often covered with deep reddish puncta, which represent 
hyperemia of the perifollicular tissues. Thirst is extreme, and degluti- 
tion is often in the highest degree painful. In severe cases the mucous 
surfaces named may speedily exhibit finger-nail- to pigeon-egg-sized 
ashy ulcerations with a lurid halo at the periphery. In children there 
may be syncope, delirium, convulsions, vomiting, or, when the poison 
has been intense, fatal results from shock of the nervous centres. This 
prodromal period usually lasts from twelve to twenty-four hours, 
though it may be prolonged for two days more. In this respect scar- 
latina is markedly distinguished from measles. This stage is termi- 
nated by the appearance of the exanthem, but the fever persists without 
abatement after the explosion ; and the other symptoms of the disease 
are then in no wise ameliorated. Authors describe three distinct types 
of the disease : the simple, the septic, and the toxic. 

The eruption in scarlatina usually spares the face, however much 
the latter may display two damask-colored cheeks under the febrile 
flush, may become tumid with the blood pumped through the throbbing 



SCARLATINA. 153 

carotids, or even may exhibit a few scanty lesions upon the forehead 
and temples. About the mouth the integument is always pallid ; this 
is far different from the picture presented in measles. The eruption is 
betrayed, first, in the form of light- or deep- red pinhead-sized puncta, 
closely agglomerated ; and, second, in the form of a superadded ery- 
thema, giving to the eye the impression of a diffuse reddish blush. 
The rash develops early about the neck and the clavicular regions, 
and it rapidly spreads to the trunk and extremities, including the 
dorsal surfaces of the hands and feet, attaining complete development 
in the course of the second day. It is then of a distinctly scarlet 
color, whence the disease derives its name in Latin, English, and 
German, a coloration frequently compared with the appearance of a 
boiled lobster. Upon the limbs it is often developed in punctate 
form, while the occurrence of a diffuse scarlet blush is most dis- 
tinctly perceived by the eye in the examination of the trunk, where 
the rash is seen to fade under pressure. In any event the ery- 
thematous blush commonly disappears before the individual elements 
of the rash are removed. The eruption can be made to disappear on 
pressure in the early stages of the affection. Drawing the finger-nail 
rapidly over the surface of the skin is followed by the formation of a 
whitish line, which persists for a time sufficient to enable one to describe 
a letter upon the skin. This period of efflorescence lasts for from one 
or two days to an entire week, during which the febrile and other 
symptoms continue unabated. 

The rash usually persists at its maximum of development from one 
to three days, the concomitant symptoms continuing without noticeable 
abatement. Among the latter may be named the occurrence of albu- 
min in a urinary secretion of diminished specific gravity, with occa- 
sionally the presence of epithelium, recognizable under the microscope 
as derived from the lining membrane of the uriniferous tubules of the 
kidney. 

Having attained its apogee, the eruption in favorable cases begins 
to fade, the part first affected exhibiting earliest a lighter shade, while 
the other pathological phenomena diminish in severity, the sore-throat, 
especially in ulcerated conditions, alone persisting. In from four to 
ten days longer the eruption disappears, leaving a brownish-yellow pig- 
mentation of the skin-surface ; simultaneously the other symptoms of 
the disease vanish. 

The desquamation which ensues as convalescence progresses is 
general, and is often proportioned in extent to the severity of the pre- 
ceding eruption, though it may be generalized after a well-nigh imper- 
ceptible exanthem. Desquamation is more pronounced and character- 
istic in scarlatina than in any other of the eruptive fevers. It may be 
superficial and furfuraceous in character, or the epidermis may fall in 
lamellated layers ; for example, the sheath of an entire finger, with the 
nail, or that of the entire palm. In this way sheets, ribbons, and 
shreds of the horny layer of the skin may fall from its surface and 
expose a new and often tender epidermis beneath. The hairs may 
simultaneously be shed. When this desquamation is finished the 
stadium of the disease may be regarded as concluded, the entire period 



1 54 1NFLAMMA TI0N8. 

lasting in uncomplicated cases from a fortnight to a month or six 
weeks. 

The complications, anomalies, and remote sequels of scarlatina 
are so numerous as to furnish a vast array of facts for the study of the 
pathologist. The reader need merely be reminded in these pages that 
the usual incubative and prodromic stages of the disease may be brief 
as to time, or be so brusquely followed by eruptive phenomena as to be 
indistinguishable. The latter may also first occur upon the extremities 
or trunk, and later on the neck and over the clavicles ; or at once 
cover the totality of the surface by a rapid explosion, or be extremely 
short-lived, or be altogether absent, or be unusually prolonged and 
visible for even a fortnight upon the surface of the body, appearing and 
well-nigh disappearing without appreciable cause. To a proportionate 
extent the stage of desquamation may be reached precociously or tardily, 
and the exfoliating process tediously be prolonged and of intense type, 
jeoparding in this manner the future of the convalescent prostrated 
by the fever which has passed or the sympathetic fever which may thus 
be awakened. 

The anomalies of the scarlatinal rash are numerous, but they depend, 
in general, less upon a variation in the intensity of the poison than 
upon the physical condition of the patient. Thus, the affected surface 
may be elevated slightly above the general level ; there may be no 
coincident pyrexia ; the skin may exhibit irregularly disposed mottlings 
and maculations, the rash may be characterized by the occurrence of 
miliary papules, minute vesicles, or purpuric lesions, well defined 
against the general scarlet color of the skin by their violaceous shade 
and due to cutaneous extravasation of blood. The rare bullous, pus- 
tular, and urticarial lesions which may appear upon the skin are acci- 
dental and bear no relation to the specific history of the disease. 

Catarrhal and parenchymatous nephritis is justly dreaded during 
the desquamative period of the malady, when it may prove fatal after 
a relatively benignant manifestation of the disease in its prodromal 
and eruptive stages. Gastro-intestinal disorders may also prove 
dangerous. An otitis externa, media, or interna may perforate the 
tympanum, destroy the ossicles, induce caries of the mastoid process 
of the temporal bone, and prove fatal by the eventual production of 
meningitis or phlebitis. To this grave list of disorders which may 
complicate scarlet fever must be added pneumonia, pericarditis, pleu- 
ritis, peritonitis, chronic purulent nasal catarrh (which may result 
in caries of the nasal bones), destruction of the cornea as a result of 
severe keratitis, persistent adenopathy of the subcutaneous glands, and 
malnutrition in many forms, which may so impair the vigor of the 
constitution as to leave the sufferer a physical wreck for the remainder 
of life. 

Septic (Anginose) Scarlatina is characterized by the gravity 
of the throat-symptoms. In such cases a parenchymatous inflamma- 
tion of the tonsils, velum, and fauces supervenes at an early period, 
with enormous tumefaction ; involvement of the submucous tissue and 
neighboring glands ; and ulcerative, suppurative, and even gangrenous 
complications which speedily may prove fatal. 



SCARLATINA. 



155 



Toxic Scarlatina (Scarlatiniform Typhus). — Another severe 
type of this disease is that in which symptoms of typhus are pro- 
nounced. Here the patient may perish within a few hours, after being 
attacked and before the eruption appears, exhibiting comatose or con- 
vulsive symptoms, indicating the profound influence upon the nervous 
centres of the intensely intoxicated blood ; or the eruption may appear 
ill developed, often livid, hemorrhagic or petechial in type, and be fol- 
lowed by albuminuria, meningitis, diarrhoea, coma, and death. 

Fig. 37. 




Microphotograph of the edge of a small colony of Bacillus scarlatinae 

B, outer edge of growth. 



A, central zone ; 



Etiology. — The disease is produced exclusively by contagion derived 
from the animal body affected with scarlatina, either mediately or 
immediately. It attacks individuals of both sexes and all ages, chil- 
dren and infants more frequently, the aged more rarely, probably in 
consequence of their respective conditions as regards immunity con- 
ferred by a previous attack, since, in general, the disease occurs but 
once in a lifetime. Individual idiosyncrasy must account for the cases 
in which unprotected infants exposed to the disease fail to receive it, a 
fact noted occasionally in epidemics of all the exanthemata. The con- 
tagious element, which is volatile in its nature, seems to be most active 
during the eruptive stage of the disease. 

Pathology. — Klein has recognized a streptococcus, isolated and 
occurring in chains, which has produced in the lower animals symptoms 
strongly suggestive of scarlatina, but irrefragable proof of the etiological 
importance of the germ has not been adduced. Class 1 describes a 
Diplococcus scarlatinae, for which he claims to have obtained an anti- 

^hila. Med. Jour., March 24, 1900. 



1 56 INFLAMMA TIONS. 

toxin proving capable of protecting guinea-pigs against the disease 
inoculated in animals which died in control-experiments in six or seven 
days. It cannot be asserted, however, that the essential micro-organism 
of scarlet fever has yet been clearly demonstrated. Scarlatina at times 
follows injuries and surgical operations, due, as Atkinson supposes, 1 to 
diminished powers of resistance to the disease. 

The cutaneous lesions of scarlatina, like those of measles, depend 
upon hyperemia and a moderate degree of exudation. The latter, 
when it occurs, is limited for the most part to the rete and papillary 
layer of the corium. The signs of the disorder are not apparent in the 
dead body unless there have been exudation of blood and the conse- 
quent formation of petechia?. 

According to Unna, the epidermis, when the disease is fully devel- 
oped, is the seat of a parakeratosis productive of scaling, while the 
prickle-layer shows neither oedema nor emigration. In the cutis 
there is a maximum of congestion without distinct oedema. The gen- 
eral vasomotor disturbance leading to a species of vascular paralysis 
is supposed to be due to changes in the nervous centres produced by 
the disease. 

The Diagnosis between measles, rotheln, erysipelas, and the erythe- 
mata in general is readily established. The sore-throat, intense fever, 
punctiform scarlet rash reaching to the border of the inferior maxilla, 
and the distinct, whitish-yellow line traceable by the finger-nail when 
passed rapidly over the surface, are all characteristic. In measles the 
macular character of the rash and its crescentic arrangement, in con- 
nection with the catarrhal symptoms, will usually be recognized. From 
erysipelas scarlatina can always be distinguished by the absence of the 
peculiar, shining, smooth, or glazed and tumid condition of the affected 
area. From all other rashes scarlet fever can be distinguished by the 
pyrexic symptoms and resulting desquamation. For the distinction 
between scarlatina and erythema scarlatiniforme the paragraphs 
devoted to a description of the malady last named may be consulted. 

Great care should be taken not to confound the drug-rashes having 
a scarlatiniform appearance with the specific disease under considera- 
tion. Thus, belladonna, in doses of 1 minim of the tincture every 
hour to the extent of four doses, has produced an abundant scarlatini- 
form eruption in children, a diagnostic point of importance in view of 
the fact that the drug named has been employed as a prophylactic 
against the disease. For eruptions of this sort due to quinine and 
other drugs the reader is referred to the pages devoted to Dermatitis 
Medicamentosa. 

Treatment. — The modern treatment of uncomplicated scarlatina is 
antiseptic and expectant, after provision is made for an abundant supply 
of fresh air, disinfection, a proper regulation of food and drink, and 
the local use of baths, tepid or cool, for the purpose of reducing the 
body-temperature. After each of these baths the skin should be com- 
pletely anointed with a fatty substance, such as cold-cream salve, scented 
almond- or olive-oil, or with vaselin. These inunctions are not only 
grateful to the patient, but they reduce the body-temperature to a 

1 Jour. Cutan. and Ven. Dis., October, 1886, vol. iv. 



VARIOLA. 157 

slight degree. All treatment other than that suggested above per- 
tains to the field of general medicine, and should be limited to the 
special conditions presented in each case. Such treatment includes the 
management of disorders of the eye, ear, throat, kidneys, and other 
viscera, the involvement of which constitutes a complication of the 
disease. 

The Prognosis of the malady should always be established with 
reserve. It is largely based upon the relative intensity of the symp- 
toms, the vigor and age of the subject, and the presence or the absence 
of serious complications. Albuminuria is rarely absent, and is not per se 
alarming ; but anasarca and other evidences of profound interference 
with the renal function are to be assigned due weight. In general, 
it may be said that a high range of temperature ; early and ulcerative 
throat-lesions ; the puerperal state ; tardy development, rapid and un- 
timely disappearance, or undue prolongation of the exanthem ; and its 
admixture with petechia? to such an extent as to indicate extensive 
hemorrhagic extravasation, are all formidable symptoms. Finally, it 
must not be forgotten that the mildest and simplest forms of the disease, 
after the fastigium is passed and convalescence is actually established, 
may terminate fatally by the supervention of uraemia, cerebral paralysis, 
or even meningitis, consequent upon secondary changes in the middle 
or internal ear. 

VARIOLA. 

(Lat. varus, a blotch.) 

(Small-pox, The Pocks. Ger., Blattern, Pocken ; Fr., Petite 

Verole ; Ital., Najuolo.) 

The variations of variola as to the severity, character, and duration 
of its symptoms are so great as to preclude complete description of this 
malady within the limits here assigned. The following paragraphs are 
therefore devoted to a sketch merely of its more commonly recognized 
characters. 

Symptoms. — ^The period of incubation of the unmitigated disease 
varies between five and twenty or more days, occupying usually twelve 
days or a fortnight. It is characterized by the peculiarities of that 
period recognized in all the exanthemata, there being few and insignifi- 
cant or no evidences of physical discomfort. The prodromic stage is 
ushered in generally by a vespertine chill, succeeded by fever, with a 
temperature rising to 104°-106° F., which is commonly associated 
with severe and characteristic pain in the loins, headache, epigastric 
pain, nausea or vomiting, and occasionally in young subjects with 
delirium and convulsions. The fever continues, with alternations of 
exacerbations and partial relief, or sensations of chilliness, during the 
second and third days. At the same time there may be faucial hyper- 
emia and moderate dysphagia. Occasionally, before the cutaneous 
exanthem appears, minute reddish papules may be recognized upon the 
buccal membrane. 

Initial Rashes (Variolous Erythema ; Variolous Rose- 
ola). — These may be either (a) erythematous in character, and gen- 



158 INFLAMMATIONS. 

eral or partial ; or (6) hemorrhagic, in the form of pure petechiae or of 
admixtures of petechial and erythematous blotches. 

On the second and third days there appears, in some cases, espe- 
cially in menstruating women and in young subjects, a cutaneous 
efflorescence, the significance of which has often been misinterpreted, 
thus leading to many errors in diagnosis. To Hebra we are indebted 
for its distinct recognition as a cutaneous prodrome in variola. The 
interpretation of this exanthem is a matter of special importance to 
the diagnostician, as many have been deceived respecting its nature 
and significance. It is characterized by the occurrence of irregularly 
disposed and distinctly outlined maculations, puncta, striae, streaks, or 
diffuse blush of bright or lurid reddish hue ; the invaded integument 
being at times slightly tumid, and thus elevated above the general 
level. The affected part may also be the seat of moderate pruritus. 
The blush may fade under pressure, but rarely does so perfectly. One 
cannot by the finger produce upon it a visible whitish spot. The rash 
occurs most often about the groins, the hypogastric region, the pubes, 
and the inner faces of the thighs; and on examining these parts the 
physician will usually discover the evidence, in adult women, of recent 
or present menstruation, or of the puerperal state. It occurs also 
about the axillae, the extensor faces of the larger and smaller joints, 
and the lumbar and clavicular regions. Often a broad area of the 
integument in these parts may exhibit a sheet or mask of dull crimson 
erythema, upon which may form pinhead- to bean-sized, dull-reddish 
papules, not losing their color under pressure, or more rarely petechiae, 
vesicles, and wheals. All these are precursory phenomena, and are 
not transformed into characteristic variolous lesions. They fade almost 
completely before the latter appear. Rarely, a few scattered papules 
may be distinguished upon the face and the arms before the variolous 
erythema fades. Often the papules in full development are even less 
profusely displayed on the site of the precedent efflorescence. The 
latter need not be necessarily regarded as a symptom of portentous 
gravity. The entire surface of the belly may be covered with a uni- 
form erythematous blush of dull-crimson hue, followed by confluent 
variola, and the patient ultimately recover. The physician, then, con- 
fronted with a deep-red erythema of the regions named, especially of 
the groins, the lower part of the belly, and the thighs of a menstru- 
ating woman affected with high fever, nausea, vomiting, and lumbar 
pain, should invariably suspect the presence of variola. 

The vividly red or empurpled rashes of hemorrhagic type occur 
most frequently in the localities named above when the disease assumes 
a grave aspect, as in hemorrhagic variola. 

The Small-pox Eruption. — The period of the eruption in variola 
is characterized, at its earliest, by punctiform, subcutaneous discolora- 
tions which photography alone can reveal. Commonly the patient 
will be seen on the morning of the third or fourth day with the face 
and scalp covered with pinhead-sized and larger, firm conical papules, 
the touch of which to the finger suggests to most English observers the 
feeling of shot. Later, these papules develop upon the trunk and 
limbs ; and in well-marked cases every portion of the body-surface is 



VARIOLA. 



159 



invaded, including the palms and soles. The lesions may be sur- 
rounded by a narrow rosy areola upon the trunk. They may be 
unproductive of subjective sensations or be slightly tender. 

As a rule, there is complete defervescence when the exanthem ap- 
pears, the patient experiencing such relief that if an adult has chanced 
not to view his face in a mirror nor to be informed of his appearance 
by those in attendance upon him, he will often regard himself as com- 
pletely relieved of his three days' illness. In other cases the febrile 
symptoms persist with a lowered temperature. 

Fro. 38. 




Vertical section of pustule at the beginning of pustulation : a, umbilication at the site of an 
excretory canal ; b, reticulum within the epidermis; c, reticulum of smaller meshes containing 
lymph- and pus-giobules. (After Rindfleisch.) 



During the first two days of the eruptive period the papules increase 
in number and become correspondingly agglomerated ; while those of 
earliest appearance become transformed into vesicles containing a trans- 
lucent serum, the roof-wall of many of them exhibiting an umbilica- 
tion. This umbilication of the vesicle is characteristic, and slightly 
different from that observed in bullous and pustular lesions. The 
central depression is disproportionately large, and about it the yet un- 
distended epidermis is often irregularly puckered or fluted. Even in 
this period the lapse of a few hours will produce a lactescent appear- 
ance in the formerly translucent contents. 

From the sixth to the twelfth day the transformation of these lesions 
into pustules is effected, the process beginning, as in all the metamor- 
phoses of the disease, in the vesicles of greatest age, those, namely, on 
the face and upper portions of the body. The lesions simultaneously 
enlarge until they are of the size of an average-sized pea, are surrounded 
with a distinctly ovoid areola, and, being fully distended, rupture the 
centrally placed filament which held down the roof-wall, consequently 
the umbilication of the pustules is lost. With this process of suppura- 
tion is awakened the so-called " secondary fever," a pathological process 
evidently not essential to the disease, as it does not occur in mitigated 



1 60 INFLAMMATIONS. 

cases. This secondary fever is born of the extensive process of suppura- 
tion occurring in the skin and other organs, and may be symptomatic, 
sympathetic, or septicemic in character. It thus varies in different 
cases with the character and severity of the process by which it is 
excited, being transitory in mild cases, and in others terminating only 
with death. At this time the patient is usually in a most distressing 
condition. The skin of the face and of other attacked regions is 
swollen, thickly covered with pustules, and the features indistinguish- 
able in the tumid and closed lids, the oedematous lips, disfigured nostrils, 
and pus-obstructed mucous outlets. Deglutition becomes painful and 
often impossible, the saliva flows from the lips, and the mucus from the 
nares dries with the pus upon the exterior of the visage. The pustules 
recognized upon the integument are represented also in the gastro- 
intestinal tract. In an autopsy of a patient dead at this stage of the 
disease the entire canal from the mouth to the anus, as also the genito- 
urinary and respiratory passages, may be completely covered with 
closely agglomerated and well-distended pustules. The career of those 
within the mouth can usually be studied by eye-observation. In this 
situation they rapidly lose their epithelial roof-wall by reason of the 
heat, moisture, and friction to which they are subjected, and then 
exhibit a reddened and excoriated surface, over which there is re- 
formation of the epidermal layer. Gangrenous complications are rare. 
Between the thirteenth and the fourteenth day desiccation begins, 
and is usually completed within from ten days to a fortnight ; the pus- 
tules rupture, and the exuded pus concretes into yellowish or brownish, 
rarely blackish crusts, or the latter are formed by the desiccation of 
the entire envelope and contents. The pulse usually at the same 
time diminishes in frequency and secondary defervescence occurs, the 
tumefaction of the integument decreases, and at times the peculiarly 
characteristic and often intolerably fetid odor from the patieut is less 
perceptibly exhaled. In from four to six weeks the course of the 
disease is completed. The immediate traces of the eruption are purplish 
and violaceous pigmentations, which slowly disappear. When cicatrices 
result they are slightly depressed, at first of a dull purplish hue, later 
dead-white, lustrous, usually symmetrical in disposition, and most 
distinct upon the surfaces exposed to the light and air, such as the face. 
Though persistent, they are rendered somewhat less deforming in the 
progress of years. When closely set together they produce a character- 
istic ridged and corded appearance, due to the elevation of narrow 
bands of unaffected integument between the depressed surfaces of scars. 
The several departures from the pronounced type of the disease described 
above present variations differing widely from the most benignant forms. 
Brief reference only can be made to these variations. 

Varioloid, whether occurring after vaccination or not, is a modified 
type of variola. With it should be classed all those forms of the dis- 
order occurring in the human subject, and described by authors under 
the titles " swine-pox," " horn-pox," etc. In these cases there may 
be a severe prodromic fever and a scantily developed exanthem ; rapid 
involution of lesions; abortion of the latter in any of their several 



VARIOLA. 



161 



stages from papule to crust ; absence of secondary fever ; transmission 
of the disease in a mild or mitigated form from one individual to 
another, so that an entire community, vaccinated and unvaccinated 
alike, may suffer from an epidemic disorder of this moderate grade 



Fig. 39. 







Vertical section of one-half of an undeveloped variola-pustule : a, old epidermis ; o,eplthelia 
of rete above the alveoli; c, new-formed epidermis ; d, alveoli filled with pus-globules; g, flat- 
tened and infiltrated papillae lying beneath the pustule. (After Auspitz and Basch.) 

without the occurrence among them of a single case of typical variola. 
It is scarcely necessary to add that a patient with varioloid, especially 
daring an epidemic, may transmit to the unprotected a malignant form 
of the disease. 

Hemorrhagic Variola, fortunately rare and too often confounded 
in the past with "black measles/' is much more formidable, viewed 
from every point. When cutaneous hemorrhages occur during the 
course of small-pox they do not necessarily indicate that the case is 
one of so-called " varioliform purpura/' since these losses may be acci- 
dents of the pathological process. In this malignant form of the disease, 
against the ravages of which vaccination often presents but a feeble 
barrier, the prodromic stage is followed by a deep purplish redness of 
the surface which is characterized by pinhead- to split-pea-sized, firm, 
closely set papular lesions, suggesting the occurrence of measles in a 
peculiarly severe form. The febrile, nervous, and other symptoms of 
the disease are proportionately intense. Ecchymoses appear upon the 
conjunctival membrane. Gradually the color of the exanthem, that at 
first disappeared under pressure, refuses thus to yield and assumes a 
bluish-black shade. Ecchymotic patches may be intermingled with 
the papules, rapidly widening to palm-sized and larger areas. The 
mucous surfaces share in these colors, being also infiltrated with effused 
blood, and the muco-cutaneous orifices are crust-covered and exhale 
an extreme fetor. Blood may escape from the bowels, bladder, mouth, 
or vagina. Signs of grave systemic and visceral complications are 
11 



162 INFLAMMATIONS. 

always present. Vesiculation, pustulation, and the typical transforma- 
tions of variolous lesions are all wanting. In the few cases observed 
by us death speedily supervened, either from shock, coma, hemor- 
rhagic infarction of the lungs, or rapid exhaustion. Intermediate 
forms between hemorrhagic and true variola are described, in which 
forms the pustules occurring in the variolous type of the disease merely 
fill with blood in consequence of accidents possessing a purely local 
significance. 

Confluent Variola is another severe form, less malignant, how- 
ever, than that just described. It is characterized by intensity of the 
prodromic fever, which often scarcely abates with the appearance of 
the exanthem. The latter is developed in deeply implanted, firm pap- 
ules, closely set together, succeeded by vesicles and pustules, which, 
as they enlarge, fully occupy the entire surface of the integument, and 
accomplish a perfect coalescence. In well-marked cases there is scarcely 
a pinhead-sized area of the entire surface of the body that is not 
invaded. The tissues become enormously oedematous; the deformity 
of the face renders the features indistinguishable. Hemorrhagic pus- 
tules and even patches of a gangrenous pulp may be intermingled with 
sheets of suppurating surface. Phonation, respiration, and degluti- 
tion are proportionately impeded or are absolutely subverted by the 
tumefaction and suppuration of the mucous membranes of the respira- 
tory and gastro-intestinal tracts. When the patient survives until the 
stage of desiccation is reached the body presents an aspect as revolt- 
ing as that ever displayed by a living being. A thick brownish or 
blackish-brown mask envelops the swollen head, trunk, and limbs, and 
the odor exhaled from the body is intolerably repulsive. All the sys- 
temic phenomena are proportionately grave, and are accompanied by 
one or more of the complications of the malady — pneumonia, pleuro- 
pneumonia, albuminuria, diarrhoea, various motor and sensory paral- 
yses, subcutaneous furuncles, and abscesses. The eyes may suffer from 
pustular and ulcerative changes in the conjunctiva, cornea, and deeper 
tissues, with resulting inflammation of every grade to panophthalmia 
and consequent loss of vision. Often the patients, with surprising powers 
of resistance, will survive until extensive sheets of crusts have fallen 
from the skin-surface, and then perish sloAvly in a typhoid condition 
with low remittent or continuous fever. Every such case does not, 
however, terminate fatally. Children may rally from the severest form 
of confluent variola, and afterward enjoy vigorous health, thus illus- 
trating the wonderful recuperative energy of the natural forces under 
the most adverse circumstances. 

Etiology. — Variola is always the result of mediate or immediate 
contagion. It is a disease both contagious and infectious, being trans- 
missible by volatile emanations from the victims of the disease. It is 
also artificially inoculable. When transmitted by the latter process 
its period of incubation is somewhat shortened, and often its successive 
manifestations become less formidable. The history of inoculated 
human variola has, however, received but little attention during late 



VARIOLA. 163 

years, since the practice properly has been forbidden by law. The 
disease is, to a certain extent, transmissible from man to the lower 
animals, and the reverse. It attacks individuals of both sexes and all 
ages, including the foetus in utero, which may be ushered at an untimely 
hour into the world, macerated or recently dead and covered with the 
lesions of variola. The disease in the larger cities is decidedly more 
frequent in winter than in summer, possibly because in the colder 
months the opportunities are greater for spread of the contagion in 
artificially heated dwellings in which numbers of individuals are 
crowded together. Islanders, long un visited by an epidemic and un- 
protected by vaccination, may suffer equally in the summer season. 

Pathology. — The parasitic nature of variola has not been demon- 
strated. Coze, Feltz, Baudouin, Luginbuhl, Weigert, Hallier, and 
Cohn have recognized micro-organisms, both bacteria and micrococci, in 
the blood of variolous patients. None of these organisms has yet been 
utilized in the production of the disease ; but Cohn l regards these para- 
sites as instances of a " twin race " of the micrococcus vaccinae discov- 
ered in vaccine-lymph. The secondary fever of the disease is without 
question septicemic, and is due to pus-cocci and their toxin. 

According to Unna, the main distinction between the vesicle of vari- 
cella and that of variola lies in the slow growth of the one and the prompt 
suppuration which is added to the fibrinoid degeneration of the other. 
The epithelium of the lower prickle-layer undergoes speedily " balloon- 
ing colliquation " not only at the apices of the papillae, but also in the 
depths of the ridges. A gradual division of the vesicle follows into an 
upper and a lower story, with a lateral extension of the cavity in the 
upper prickle-layer, a somewhat characteristic oedema, and mitotic pro- 
liferation of the semisolid cushion below. The umbilication is pro- 
duced less by the action of centrally placed epithelia acting as guy- 
ropes than by the enormous force of the exudation at the periphery in 
contrast with the slight activity of the central parts, as a result of which 
the latter are simply " left behind/ 7 Gradually there follows a dense 
collection of plasma-cells in the adventitial sheaths of the blood-vessels. 
The latter subsequently dilate, and the line of demarcation between 
the cutis and rete becomes well-nigh indistinguishable on account of 
the stream of leucocytes thither. Healing begins at a later stage by 
the formation and gradual contraction of a thin layer of epithelial cells 
lying close to the connective tissue and extending from all sides beneath 
the pustule. 

Diagnosis. — The difficulty attending the diagnosis of variola in its 
prodromic and earliest eruptive stages, from measles, is considered in 
the description of the latter disease. The general demand, indeed, 
upon the physician for an exact and definite diagnosis of every case 
before its complete evolution, is founded upon an erroneous conception 
of possibilities, and the sooner this is generally recognized the better 
for all concerned. A delay of even a few hours will often verify or 
remove a suspicion. Fully as much mortification on the part of the 
physician and damage to the best interests of the patient may result 
from an error in one direction as in the other. The wisest course in 

1 See Magnan, loc. cit., p. 411. 



164 INFLAMMATIONS. 

every doubtful case is to admit the doubt and to visit the patient fre- 
quently for the purpose of observing the development of the disease 
until that doubt is removed. Typical cases of variola are recognized 
with ease from the character of the symptoms presented. Syphilis and 
acne are always distinguished by the absence of fever and their relative 
chronicity. 

The Prognosis of variola is largely dependent upon the degree of 
protection conferred by previous vaccination. Independent of vacci- 
nation, the age and vigor of the patient, the presence or absence of an 
epidemic of severe or mild type, the extent of the eruption, and the 
character of the surroundings of the patient are elements of prime 
importance. Very young and aged subjects, women pregnant or in 
the puerperal state, and, as Hebra has shown, those who have suffered 
from a previous attack of the same disorder, are all unfavorably dis- 
posed with respect to the final result. Confluent and hemorrhagic forms 
of the disease are, naturally, the gravest. Unmitigated variola, under 
the most favorable circumstances, is one of the greatest scourges of iiu- 
manity, and as such will probably always destroy a frightful propor- 
tion of its victims. At the same time the conscientious physician 
needs to be impressed with the fact that, under the most discouraging 
circumstances, the patient, disfigured to the greatest extent by an en- 
velope of blackened crust, and in a state of extreme physical prostra- 
tion, with many of his bodily functions almost completely suspended, 
may even from the midst of such peril be won back to life and vigor. 
The assiduous attentions of a skilful nurse, guided by the inspiring 
presence and councils of a physician who is himself fearless of the 
malady, will often achieve the result. Upon the latter point it is 
interesting to note that physicians in active practice who do not hesitate 
to expose themselves freely to the disease in the discharge of the duties 
of their profession rarely suffer in their own persons. 

The Treatment of variola should, in general, be limited to the 
indications presented in each case. ~No remedies can be employed 
which have the least power to abort the disease. Kaposi calls atten- 
tion to the striking fact in this connection, that syphilis, for many of 
the manifestations of which mercury is a specific, is a disease the second 
incubation-period of which is measured by weeks, and yet neither by 
excision of its initial sclerosis nor by mercurials can the subsequent 
manifestations of the disease be completely prevented. Certainly no 
specifics are recognized as of value in variola. The patient should be 
kept in a relatively dark room with an abundant supply of fresh air 
of a uniform temperature, and antiseptic solutions should constantly 
be at hand into which all the ejecta are received immediately. He 
should be given ice when this is acceptable to the palate, cool water 
ad libitum, and his strength should sedulously be supported by a liquid 
animal diet. The body may be sponged with or bathed in cool or 
tepid water as often as is grateful to the patient. In severe or con- 
fluent cases the immersion of the body in the continuous warm water- 
bath is followed by brilliant results in hastening the desiccation and 
fall of the crusts and subsequent repair. A bath of this character given 
for merely two or three hours in the day is often of great value. With 



VARICELLA. 165 

and without these external measures gargles of potassium chlorate, 
myrrh, honey, or carbolic acid will be found acceptable to the mouth 
and palate. The constant attention of an efficient nurse bestowing 
assiduous care upon the mouth, the skin, and the eyes may be regarded 
as an essential part of all sound treatment. 

With a view to the prevention of pitting, no measures of a therapeu- 
tic character will prevent the occurrence of a distinct cicatrix whenever 
pus has eroded or otherwise destroyed the integrity of the papillary 
layer of the coriuuL Every effort, therefore, should be exerted to 
prevent extension of the suppurative process to the true skin. The 
following measures have approved themselves as of practical value : 
First, the sick-room should be moderately darkened and yet be amply 
provided with fresh air. Second, a solution of pure sodium hypo- 
sulphite should be administered night and day in the dose of from 15 
to 20 grains (1.-1.3) every three or four hours. The variolous lesions 
pursue a milder course under this internal treatment, and in some 
cases even the vesicles shrivel before pustulation is fairly begun. 
Third, the skin of the face, after sponging with a weak formalin lotior, 
should be anointed with a bland fatty substance such as vaselin, almond- 
oil, or fresh lard, and over the unguent may be laid silk-enveloped 
compresses, dipped in tepid, weak solutions of carbolic or boric acid, or 
of thymol. The anointing of the surface before the application of the 
lotion is commonly more grateful to the patient, but the skin may 
constantly be moistened with the aqueous lotion alone. Here, again, 
the assiduous attention of the nurse is a matter of importance. The 
powder of europhen topically is often applied with advantage. 

The edges of the eyelids should daily be anointed with freshly 
prepared cold-cream salve. Puncture of the cornea may be required 
for the relief of hypopyon. Diarrhoea and other symptoms of visceral 
derangement should be relieved by appropriate medication. As a rule, 
the administration of narcotics for the relief of pain is objectionable. 
Throughout the course of the disease the strength of the sufferer should 
be supported by a generous use of animal broths or of milk; in typhoid 
conditions a judicious employment of stimulants may be necessary. 

VARICELLA. 

(Chicken-pox. Ger., Spitzblattern, Wasserpocken ; 

Fr., Variolette.) 

Symptoms. — This disease has an incubative period lasting from ten 
days to a fortnight, after which there is occurrence of malaise, chilliness, 
and languor. The patients are usually children, who may suffer thus 
from fever of a moderate grade (99°-100° F.) lasting from a few hours 
to two or three days, after which defervescence is commonly complete. 
With the onset of the fever or even without, the rash appears, first on 
the head and trunk, in the form of rosy macules or slightly elevated 
lesions lacking the characteristic " shot-like " feeling of the variolous 
I papule. These macules rapidly become vesicular, the lesions being 
pinhead- to pea-sized, limpid, superficial in situation, differently shaped 
from variolous lesions, and very rarely umbilicated, puckered, or 



166 INFLAMMATIONS. 

" fluted " as in small-pox. The macules appear in successive crops, 
and are often surrounded by a faint pinkish or reddish halo. Their 
contents become cloudy or lactescent rather than puriform, and they 
desiccate as early as the second day, forming thin, light, superficial 
crusts. The lesions may be abundant in one region, as, for example, 
over the back or the chest, but are never both abundant and generalized 
and never confluent. Like variolous lesions, they extend at times to 
the mucous surfaces of the eyes, the mouth, and the genital regions. 
Occasionally they are productive of pruritic sensations. Often the course 
of the disease is so mild and the exanthem so slight as scarcely to 
attract attention. Cicatrices result only in places, chiefly the face, 
where the lesions have been subjected to local irritation. 

Diagnosis. — The doctrine that varicella is a mitigated form of 
variola has been practically abandoned in consequence of the researches 
of pathologists. It is of vast importance that the essential differences 
between the two diseases be exactly and generally recognized. 

In variola the invasion-period of relatively fixed limits, the speedy 
transformation of the lesions into minute, firm papules, their early 
appearance on the exposed parts of the face and wrists, the age of the 
patient, the thermic variations, the prodromic rashes, and the rapid 
transformation of the papules into umbilicated vesicles, are all 
important diagnostic points. In varicella the trunk usually exhibits 
the greater number of lesions, which appear also in successive crops. 
Beside the characteristics of the cutaneous lesions the catarrhal symp- 
toms of measles and the sore-throat of scarlatina will point to the 
nature of these disorders. Impetigo contagiosa is to be carefully dis- 
tinguished from varicella, since the two affections occur at times side 
by side in one hospital ward, and occasionally the former succeeds the 
latter. The lesions of impetigo contagiosa are often larger, generally 
more persistent, and the crusts bulkier than in varicella, and the 
patients rarely exhibit pyrexic symptoms. 

Pathology. — According to Unna, the varicellous process begins 
with a " reticulating liquefaction " of some of the prickle-cells of the 
central and upper portion of the rete in which the first congestive focus 
is seen. The complete liquefaction of the contents of the loculus is fol- 
lowed by confluence of adjacent cavities and rapid dilatation to the 
point of formation of a vesicle, the non-liquefied and persistent epithe- 
lium being compressed so as to form the septa, while the cells above 
produce similarly the roof- wall. The epithelial cells of the base undergo, 
on the other hand, " ballooning colliquation " (transformation of cells 
into hollow spheres or balloons having the form of peculiar giant-cells), 
a change affecting especially the centre of the pock, its lateral margins, 
and even at times its septa. Internally, these ballooned cells merge 
into simple oedematous epithelium with constricted nuclei. Careful 
observation of the lesions of varicella demonstrates that the vesicles are 
as distinctly divided into septa as are those of variola. These lesions 
are never monolocular. Their benign course is explained pathologi- 
cally by their superficial position, by the absence of purulent infection, 
and by early repair with young epithelium. The absence of umbilica- 
tion is explained by the acuity of the process. Bareggi, Guttmann, 



VACCINIA. 167 

Pfeiffer, and others claim to have discovered micrococci and protozoa 
both in the blood-corpuscles and in serum obtained from subjects of 
the disease ; but no pathogenic relation of these germs has been estab- 
lished. 

Treatment. — The management of uncomplicated cases of varicella 
is limited to the avoidance of exposure to sources of aggravation of 
the affection. Often a dusting-powder may be applied over the sur- 
face after a lotion of thin oatmeal-water. Cases complicated by the 
accidents of exposure or by the intensity of the disease are to be 
treated by the resources of general medicine according to the indica- 
tions presented. 

VACCINIA. 

(Cow-pox. Ger., Kuhpocken; Fr., Vaccine.) 

The limits of this volume forbid a discussion of the interesting 
questions concerning the relations of cow-pox as it occurs spontane- 
ously in the milch cow, to human variola. A careful collation of the 
results obtained by a large number of vacciniculturists of recent days 
renders it clear that it is a matter of great difficulty to transmit variola 
from man to the heifer ; that where this rare result is obtained the 
lymph derived from the lesions on the udder or the belly of the animal 
is liable to produce variola when retransmitted to man ; and that spon- 
taneous cow-pox alone seems to furnish a lymph which is safely inoc- 
ulable in generations to the human race. 

Of greater importance is it to note that, either by arm-to-arm vac- 
cination as was formerly extensively practised, or by the use of the 
animal virus which is now well-nigh exclusively employed, there has 
been conferred upon millions of human beings a degree of protection 
against variola the value of which is beyond estimate. In both methods 
the lymph is originally derived from the female of the bovine race, 
preferably during the puerperal state, and its sources are the vesicular 
lesions of vaccinia spontaneously arising or artificially cultivated about 
the teats, udder, and adjacent parts. The introduction of this lymph 
into the skin of the human subject is termed "vaccination." 

The operation of vaccination should eliminate to the largest extent 
the possibility of transmitting any other contagious disease than the 
one intended. With this object in view, no better instrument can be 
devised than a clean needle, one which has been properly disinfected 
and not previously employed for any purpose. The skin of the part 
selected for vaccination being first cleansed antiseptically and sub- 
jected to slight tension by the left hand, the vaccinator should scratch 
or scrape off the epidermis with the needle, held in the right hand, 
by a series of parallel and crossed strokes, so as to make three or 
four superficial erosions three inches or more apart. Each of these 
multiplex wounds should have the size of the nail of the little finger, 
and should in no case bleed, but merely ooze with serum slightly 
tinged with blood. At such points the lymph, preferably extruded by 
air-pressure from a slender glass-tube in which it has been hermetically 
sealed, is to be slowly and thoroughly rubbed in. 



168 INFLAMMATIONS. 

Between the third and the fourth day after a successful vaccination 
of the unprotected a light-reddish, pinhead-sized papule rises at each 
inoculated point. Between the fifth and the sixth day it becomes 
transformed into a translucent, well-distended, occasionally umbilicated 
vesicle, which, when single, may attain the size of a finger-nail. Spring- 
ing from the multiplex abrasions described above, a minute papule 
usually forms at each point of intersection of the crossed lines pro- 
duced by the scratching with the needle, and the subsequent vesicles 
coalesce, thus forming a compound lesion of rather peculiar aspect. 
It appears often as a small coin-sized plaque, elevated to the extent of 
a line or more beyond the general level of the skin-surface, with a rim 
formed of numerous discrete or confluent vesicles, which in either case 
are closely set together. The compound plaque seems to develop after- 
ward as a single lesion, its centre being depressed. After the ninth 
day the fluid becomes opalescent, and desiccates in a reddish-brown 
crust, which, examined in section in a good light after it is completely 
dried, exhibits a smooth, homogeneous, shining appearance with a color 
having the shade of amber. 

Fully as important as any of the metamorphoses of this lesion is 
its rosy-red areola, in the absence of which it has been held that there 
is not proper protection. The areola, which endures from about the 
fifth to the tenth day, completely encircles the compound vesicle in 
the form of a halo having a diameter of several inches, the tissue it 
invades being often slightly tumid. When the pathological process in 
the focus of this areola is intensified, either as the result of the irritant 
character of the virus or from extrinsic causes (undue exertion of the 
vaccinated part), the areola may spread down the arm or over the 
thigh or leg and eventually cover a dense, brawny, and deeply red- 
dened integument. Dermatitis, erysipelas, lymphangitis, adenopathy, 
and severe grades of inflammation of the subcutaneous tissues may for 
similar reasons complicate the process, which may terminate by central 
sloughing, ulceration, slow repair, and the production of an atypical 
cicatrix. Ordinarily the subjective phenomena are limited to a mild 
or annoying itching of the vaccinated surface ; in other cases severe 
burning pain, a feeling of tension, and even sympathetic fever may 
be aroused. 

The acme of a successful vaccination is usually attained between the 
tenth and the fourteenth day, after which the symptoms of the dis- 
order gradually subside, the crust falling, if undisturbed, in the course 
of the ensuing week. When "animal" virus is employed the duration 
of each of these stages of the disease is usually somewhat prolonged. 

The cicatrix, at first slightly reddened or pigmented, gradually as- 
sumes the dead-white appearance of scars in general. When typical 
it is slightly depressed, circular, not irregular nor deformed by ridges, 
cords, or bands, and " foveolated," exhibiting a series of peripheral 
pits or depressions, each of which represents the site of a former 
minute vesicle of simple type. The degree of protection is based in 
part upon the multiplicity of typical cicatrices. 

The complications of vaccination are due : first, to the character of 
the virus employed ; second, to the character of the soil in which it is 



VACCINIA. 169 

implanted ; and, third, to the external accidents to which the vaccine- 
lesion is subjected. Respecting the first of these sources, there are few 
contagious diseases beside syphilis which may be transmitted by vac- 
cination. When this accident occurs it may be due either to syphilis 
in the vaccinifer or to the use of instruments soiled with infectious 
secretions. The lymph from a typical vaccine-vesicle upon the skin 
of an intensely syphilitic vaccinifer will necessarily transmit syphilis if 
accidentally it be commingled with either blood or the products of 
inflammation at the base of the pock. The stage and intensity of the 
disease in the vaccinifer are elements which cannot be ignored in fore- 
casting the issue. The vaccine-lesion may complete its career during 
the incubative period of the initial sclerosis, the existence of which at 
the site of vaccination is commonly declared later by induration, ulcer- 
ation, pigmentation, and axillary adenopathy. The occurrence of a 
generalized syphiloderm before the chancre of vaccination is completely 
healed may be the first symptom to arouse suspicion. The popular 
impression regarding the frequency of this accident is erroneous. The 
rarest of all modes of transmission of syphilis is that by vaccination. 
In all such cases the possibility that the syphilis may be hereditary 
and its symptoms simply coincident in point of time with those of 
vaccinia, should not be forgotten. 

Exceedingly dangerous is that vaccine-virus, however good its early 
character, in which decomposition or putrefactive changes have oc- 
curred after exposure, in a liquid form, to the action of heat and the 
atmosphere. Vaccination with lymph thus changed has rapidly been 
followed by fatal results, in consequence of the supervention of pyaemia 
or septicaemia. 

Complications of vaccinia, due to the character or predisposition of 
the tissues in which the virus is introduced by the vaccinator, are 
usually ascribed by the ignorant or the prejudiced to the causes just 
considered. Post hoc ergo propter hoc is the sole logic of the unin- 
formed. In this way each of a series of maladies has been ascribed 
to "impurities" and "humors" introduced by vaccination. The argu- 
ments used in support of these assumptions are without basis in the 
most of cases. The cutaneous symptoms which may be awakened by 
vaccination are numerous. It will be remembered that the contents 
of the typical vaccine-vesicle are auto-inoculable, and that thus the 
scratching by young patients may produce an abundant crop of typical 
or torn vesicles upon the arms, legs, thighs, hands, and fingers. But 
vaccination may awaken in the patient, as explained above, a latent 
syphilis, as also a list of cutaneous disorders not contagious in 
character. Thus, an erythema (roseola vaccinia, vaccinola, etc.), 
eczema in many of its forms, and other exudative processes may be 
aroused first in the integument by the turbulence of a successful 
vaccination. 

These rashes may become generalized, and may even assume a for- 
midable appearance. They may appear at any time from the second 
to the fourteenth day after vaccination. A scarlatiniform rash, dif- 
fused or in patches, is described by some authors as occurring in this 
way, accompanied by mild fever, and resembling German measles. 



170 INFLAMMATIONS. 

Similarly generalized eruptions, resembling erythema multiforme, ery- 
thema scarlatiniforme, eczema, psoriasis, pemphigus, urticaria, impetigo 
contagiosa, varicella, and other cutaneous disorders, may appear for the 
first time within the limits named above. They usually disappear 
within a brief time after the vaccine-vesicle has completed its involu- 
tion, and may be followed by slight desquamation or pigmentation. 
Very rarely vaccinia is followed by purpuric symptoms and by the 
development of lupus-nodules at the site of inoculation. 

Anomalies of the vaccine-vesicle are occasionally noted as to shape, 
career, and resulting cicatrix, which are difficult to explain. Thus, 
the papulo-vesicle may not exhibit an umbilicated centre, or may com- 
plete its course within unusually short limits; or a harmless ulceration 
may progress beneath its crust, requiring a week, or even more, for 
complete cicatrization. The so-called " raspberry-sore " results from 
coalescence of small papules, so as to form a pigmented tubercle. The 
scars resulting from many of these irregular and non-protective results 
of vaccination usually form atypical cicatrices, being, in one case, small 
palm-sized, deforming, corded, and representative of large tissue-loss ; 
and, in another case, irregular and inconspicuous. 

Lastly, the complications of vaccinia due to external accidents of 
the lesion are usually inflammatory in character. The excessive use 
of the vaccinated arm in labor and of the vaccinated leg in walking, 
standing, and other exertion, may induce, as indicated above, every 
grade of dermatitis and even ulcerative changes in the site of the in- 
oculation, as a result of the intensity of the process. For these acci- 
dents rest is essential, with the free use of a dusting-powder over the 
inflamed surface. In exaggerated cases lotions of lead- water and opium 
may be employed. These conditions are usually relieved without 
difficulty as soon as the part is put to rest. The atypical scar which 
results seems to be in such cases as protective as others, if only the 
accident have occurred to a typically progressing lesion with distinctly 
perfect areola. Vaccine-cicatrices are to be distinguished in anomalous 
situations from maculae atrophica?, the scars of syphilis, and other scar- 
leaving disorders. 

Genekalized Vaccinia (vaccinal eruptive fever) usually results 
from a non-cutaneous introduction of vaccine virus; and is characterized 
by the production of vesicles of vaccinia in crops, which resemble 
strongly the lesions of variola. Supernumerary vesicles form, at times 
on the mucous surfaces of the mouth, with febrile symptoms and sub- 
sidence of the eruption in about three weeks. 

Pathology. — In the vaccine vesicle, according to Unna, the epi- 
thelium undergoes ballooning as in variola and varicella, but in the 
first-named affection the two forms of degeneration, " reticulating col- 
liquation" and " ballooning," are peculiarly commingled. The greater 
prominence of the ballooning may be due in part to the juvenile char- 
acter of even the oldest cells. The existence of an inoculation- wound 
has a marked influence on the microscopical picture, the resulting 
fissure being filled with blood-disks inside the horny layer, w T hich is 



ERYTHEMA. 171 

somewhat thickened. In vaccinia, as in the two maladies which path- 
ologically it most resembles in its lesions, the formation of the vesicle 
is by chambers, the septa consisting of collections of cells (granular and 
others) which seem to be the remains of the sweat-pores. 

Micrococci have been recognized by Cohn in vaccine-lymph. These 
have been named " micrococci vaccinae," but their relation to similar 
organisms discovered in the blood and tissues of variolous patients has 
not been determined. Wolff 1 claims to have cultivated these organisms 
through fifteen generations. Strauss demonstrated their existence in 
the vaccinal pustules of the calf. 2 

Lipp, of Gratz, reported to the International Medical Congress, in 
London, that he had recognized great similarity, if not identity, be- 
tween the micrococci of vaccinia and those of variola that he had 
cultivated to the second generation, but had then been unsuccessful in 
producing inoculation-effects. These organisms were always arranged 
in groups of four or multiples of four. 

Steinhaus 3 reports that Unna's ballooning and reticular degenera- 
tions play no part in the formation of the pock in animals. The process 
is, instead, Ziegler's dropsical degeneration with typical mitoses, but 
without division of the cell-nucleus. 

Treatment. — The management of the severer types of vaccinia and 
of the complications of the disease is to be conducted in accordance 
with the principles of treatment described in connection with derma- 
titis venenata and acute eczema. 



ERYTHEMA. 

(Gr. epvdrjjua } redness. ) 

(Rose Rash. Ft., Erytheme ; Ger., Hautrothe.) 

Erythema is, strictly speaking, a mere redness of the skin due to 
congestion of the cutaneous vessels. Much confusion has arisen from 
the fact that the term is used to indicate a mere symptom, and is also 
applied to two fairly well-defined groups of cutaneous diseases. Red- 
ness of the skin, varying greatly in its intensity, duration, and distri- 
bution, is seen in many different conditions and diseases of the integu- 
ment and of the general economy. In the so-called "idiopathic 
erythemas " the redness may be the sole symptom recognizable, but it 
is usually produced by some definite internal or external form of irri- 
tation, or is symptomatic of systemic disease. Erythema may simply 
be hypersemic and be due to a congestion, active or passive, of the 
cutaneous blood-vessels, or the process may go on to exudation and 
inflammation. From a pathological point of view it is evident that no 
sharp line can be drawn between erythema hypersemicum and erythema 
exudativum, yet for clinical purposes it is convenient to make this dis- 
tinction. 

1 Berlin, klin. Woch., January 22, 1883. 

2 See Magnan, loc. cit. 

3 Gaz. Lekarsk., 1898, xviii., p. 274. 



172 INFLAMMATIONS. 



ERYTHEMA HYPEKJEMICUM (seu SIMPLEX). 

Erythema simplex is a coloration of the skin in various shades of 
redness, temporarily disappearing under pressure, the lesions differing 
in size and shape according to the extent and degree of the hyperemia 
by which they are induced. 

Simple erythema is seen in the phenomenon known as blushing. 
Ordinarily this is a purely physiological and transitory hyperemia due 
to emotional causes. Cases occur in which the hyperemia thus 
induced persists for hours, together with palpitation and other evi- 
dences of circulatory disturbance. Here the erythema is symptomatic 
of either physical or mental disorder. With the former may be classed 
those disorders in which portions of the face remain flushed after eat- 
ing, exercising, exposure to heat, etc. 

Under idiopathic erythema, have been classed simple forms of 
erythema for which no cause is recognized. In the great majority of 
cases a careful search will disclose the disease or condition of w T hich 
the erythema is but a symptom. The cause may be found in external 
irritation too slight and too transient to produce a dermatitis, in dis- 
turbances of the alimentary canal, in the nervous irritability of children 
due to "teething," in a drug-idiosyncrasy, or in one of many other 
derangements of the general economy. Again, the erythema may be a 
more or less important diagnostic symptom of graver constitutional 
disease, as in the exanthemata, typhoid fever, etc. The color in ery- 
thema may vary from a delicate pink or rosy shade to a dark-reddish 
hue; it may be transitory or persistent, and may be limited to circum- 
scribed points, or macules, or be displayed in diffuse, ill-defined areas. 
The character, duration, and distribution of these rashes when due to 
simple causes often depend largely upon the peculiarity of the indi- 
vidual. The same source of disturbance or irritation may produce 
different effects on the skins of different persons. 

Erythema traumaticum is the result of friction, rubbing, pressure, 
scratching, or similar external contacts. It is observed, for example, 
in the part pressed by the pad of a truss ; in the colored circle left 
about the leg where a tight garter has been worn ; and the sides of the 
nose where pressure is exerted by a newly applied pair of eye-glasses. 
These traumatic hyperemias are readily converted into exudative 
affections if the traumatism be long continued. Intermittent pressure 
upon the skin permits restoration of the vascular equilibrium, and the 
integument responds to the demand made upon it by increasing in 
thickness ; continuous pressure, on the contrary, admits of no such 
restoration, and the tissue finally becomes thinner, and yields before 
the agent inflicting the injury. Inflammation resulting in ulceration 
may finally supervene. 

Erythema Caloricum (Erythema ab Igne). — Extremes of heat and 
cold, either natural or artificial, are sufficient to induce transitory red- 
ness of the skin-surface. In the erythema induced especially by solar 
heat there is frequently an increase in the pigmentation of the surface, 
as in the production of freckles and "tan" in persons whose skins are 



ERYTHEMA HYPERMMICUM. 173 

reddened by the sun. The darker, brownish, and chocolate-colored 
stains of the hands and face are thus induced. 

Erythema ab igne occurs in annular and odd-looking gyrate patches 
on the anterior surfaces of the legs in cooks, firemen and stokers, and 
in persons exposing that portion of the body to the direct action of 
heat. The annular patches may be several centimetres in diameter, 
and vary in shade from a light to a deep red or even a purplish tint, 
intense, often permanent pigmentation resulting as the erythema sub- 
sides. Perry 1 believes that the phenomena are due chiefly to a blood- 
disintegration occurring in and around the walls of the plexus of super- 
ficial veins. He adds that the name ephelis ab igne better describes 
the condition. 

Erythema Venenatum. — A number of chemical substances, dyes, 
and vegetable poisons are capable of producing transient hyperemia 
of the skin. Among these may be mentioned cantharides, capsicum, 
mustard, anilin, chloroform, .ether, arnica, and several of the essential 
oils. 

Erythema Gangrenosum. — Under this title several singular affections 
of the skin have been described, in which erythematous patches 
appeared and were followed by greater or less extensive destruction of 
one or more of the several layers of the skin. T. C. Fox, in a descrip- 
tion of the appearances in two cases of the affection under his observa- 
tion, concludes that these patches are the symptoms of a feigned disease, 
or of one produced artificially for the purpose of exciting sympathy, 
etc. The majority of these cases are more properly described with 
dermatitis gangrenosa. 

Erythema Lseve is an obsolete term once employed to designate the 
shining redness of the skin in oedema of the lower extremities following 
any disorder sufficient to induce local tumefaction. 

Erythema Paratrimma is a term once employed for the form of deep 
and lurid redness preceding the formation of a bedsore, an accident 
which under modern methods of nursing is as obsolete as the name 
once given it. 

Erythema Fugax is a term applied to a transitory redness of 
the skin, usually occurring in small areas, which appears and dis- 
appears very much as do the lesions of urticaria ; in fact, it may well 
be considered a mild form of urticaria in which typical wheals are 
absent. 

The Diagnosis of simple erythema is not difficult, since without 
exudation there is an absence of all other elementary or secondary 
lesions of the skin. The difficult point in diagnosis is to establish the 
cause. 

The Treatment of most of the erythemas depends entirely on the 
underlying cause. For the condition of the skin little if any treat- 
ment is necessary. A dusting-powder is often of service, and if there 
be itching or burning an antipruritic or soothing lotion may be indi- 
cated. Ointments are rarely required. 

1 Brit. Jour, of Derm., 1900, p. 94. 



174 INFLAMMATIONS. 

SYMPTOMATIC ERYTHEMA. 

This may be of either active or passive form. A long list of phys- 
iological and pathological causes operating upon the system at large are 
capable of inducing active symptomatic hyperemia of the skin. The 
large majority of these erythemas are toxic in origin. The redness 
may be generally diffused, or occur in surface-mottlings and markings 
of various sizes and shapes. Thus, the skin of the face may be red- 
dened intensely in a paroxysm of rage ; and that of the limbs of a teething 
child be covered with rosy maculations in consequence of the reflection 
to the surface, through the medium of the nervous system, of the irri- 
tation induced by the eruption of a tooth. In consequence of the rosy 
tint assumed by several of these rashes they have long been termed 
u roseola," a name which to-day is held to describe a symptom rather 
than a disease. The word roseola is still associated in the minds of 
many with the earliest syphiloderm, but that eruption is now designated 
by the best authors as the erythematous, or macular, syphilide. 

Roseola infantilis is sometimes described as a distinct affection 
in which there are fever and constitutional disturbance lasting a few 
hours or even a few days. The exanthem varies greatly in extent and 
distribution. It is usually macular or punctate, but may be finely 
papular ; it is most common on the trunk, but may appear on other 
parts of the body ; it may closely simulate scarlatina or measles. It is 
probable that these phenomena are always the manifestations of some 
systemic or local disorder, and not, as the name w r ould indicate, due to 
a definite disease. 

Several of the severer constitutional maladies betray their morbid 
influence upon the central nervous system by a prompt efflorescence of 
this character. A lurid erythema of the axillary or the inguinal re- 
gion may precede by several days the eruption of confluent variola. 
Cholera, cerebrospinal meningitis, diphtheria, enteric and other fevers 
are thus at times accompanied, preceded, or followed by rashes. A 
study of these rashes is of the utmost importance to the diagnostician. 
Children who are really susceptible to the disease are often supposed 
to possess an immunity from scarlatina, as the symptomatic erythema 
previously displayed was misconstrued. Vaccination may be followed 
in from one to eight or nine days by a macular or more diffuse ery- 
thema of the trunk and extremities, usually accompanied by some 
febrile reaction. 

Symptomatic passive erythema is usually characterized by a cyan- 
otic, purplish or darker hue of the integument, resulting largely from 
accumulation in excess of carbon dioxide in the blood. The tempera- 
ture of such skins is either normal or below the normal standard, as in 
those cases in which gangrene ensues. A long list of conditions may 
be named in which these symptoms are noted, including derangement 
of the blood-vessels from imperfect innervation, direct pressure, or 
disease of the heart or vascular walls. 

These erythemas may be either circumscribed in area or general- 
ized. The term " livedo " is applied to circumscribed regions of passive 
erythema. Sometimes the nose, cheeks, fingers, or toes exhibit this 



SYMPTOMATIC ERYTHEMA. 175 

form of disease. The so-called " symmetrical gangrene " of the fingers 
belongs to the same category. Cardiac cyanosis, or Morbus Coeruleus, 
is a name given to a generalized dark-blue discoloration of the entire 
surface, due to continued patency of the foramen ovale. 

Erythema Scarlatiniforme 

(Scarlatinoid Erythema, Desquamative Scarlatiniform 
Erythema, Scarlatinoid e, Erythema Punctatum, Eoseola 
Scarlatiniforme, " Scarlet Rash," Erytheme Infectueux, 
Dermatitis Scarlatiniformis Recidivans). — Erythema scarlatini- 
forme is a name given to an eruption arising from a large number of 
causes and varying considerably in character, but having a tendency 
to simulate the rash of scarlatina. This condition has been described 
as an idiopathic disease, but it has so often been demonstrated to be 
a symptom only of other disorders that its existence as an independent 
affection may well be doubted. 

Besnier, Brocq, and other French authors describe an erytheme sca/*- 
latino'ide, which is acute in type, and which is always secondary to 
other infectious diseases, to auto-toxsemia, or to medicinal or food-tox- 
semia ; and an erytheme scarlatiniforme desquamatif, which is subacute 
in type, and which may be idiopathic, secondary to other infectious 
diseases, or be produced artificially by drugs. While it is often clin- 
ically convenient to make a distinction between acute and subacute 
forms of scarlatiniform erythema, there are no good pathological or etio- 
logical grounds for making such distinctions, since a given drug or 
given form of intoxication may produce the acute type in one individual 
and the chronic form in another. 

Symptoms. — In the acute type, which is the more common of the 
two forms, the rash may be preceded by a day or two of fever and 
other evidences of constitutional disturbance, or it may appear sud- 
denly without premonitory symptoms. The exanthem spreads rapidly 
and in a few hours, or at most in two or three days, reaches its full 
development. The rash may be punctiform, macular, or diffuse, and 
the color may be any of the shades of red, but it is usually a bright 
scarlet. In some instances it has all the appearances of a typical 
scarlatinal rash, except that it may begin on any part of the body, 
often sparing the face, and that desquamation begins much earlier 
(three or four days after the onset of the malady) than in scarlatina. 
There are usually some fever, malaise, and other constitutional disturb- 
ances that may vary greatly in intensity, depending upon the disease of 
which the exanthem is a symptom. The mucous membrane of the 
mouth, the tongue, and the fauces may be reddened or be denuded of 
epithelium, but the characteristic strawberry-tongue of scarlatina is want- 
ing. The nails and the hair may be shed, but only in exceptional cases. 

Desquamation usually begins in from two to six days, sometimes 
before the disappearance of the rash, and it may even occur on sur- 
faces which had not perceptibly been reddened. The scales are usually 
furfuraceous, but they may be large and abundant ; in rare instances 
the entire epidermis of the hand may be shed in glove-like form. 



176 INFLAMMATIONS. 

The subacute forms of scarlatiniform erythema differ from those 
described above in that constitutional disturbances are less, the rash 
has a greater tendency to be diffuse, and, together with the desquama- 
tion, may persist for weeks or for months, recurrences being frequent. 
Occasionally cases are found in which recurrences are so frequent as to 
make the condition practically continuous and clinically indistinguish- 
able from the milder forms of dermatitis exfoliativa. 

Etiology. — Idiosyncrasy is a most important factor in the etiology 
of those forms of erythema which appear in certain predisposed indi- 
viduals as a result of causes totally insufficient to produce the same 
phenomena in most persons. The exciting factor is usually, if not 
always, some form of toxaemia. Among many causes reported are : 
infectious diseases, septicemic conditions, toxaemias of varied origins, 
peritonitis, rheumatism, ague in children, gonorrhoea, abscess, empyema, 
uraemia, tuberculin-injections, sewer-gas poisoning (Crocker), certain 
articles of food, and many drugs. The causes are sometimes external, as 
when following mercurial inunctions, exposure to high temperature, etc. 

Diagnosis. — It is most important to distinguish this rash from that 
of scarlet fever. Commonly the diagnosis is not difficult, as in ery- 
thema scarlatiniforme the constitutional symptoms are slight ; the rash 
appears rapidly, beginning on any part of the body ; the lesions are 
exclusively cutaneous ; desquamation begins early and is extensive ; 
the fauces though red are not swollen ; and there is absence of the 
strawberry-tongue and of all history of contagion. Occasionally the 
rash may closely resemble that of measles or rotheln, but the history 
of the case and the absence of other symptoms peculiar to these affec- 
tions should make the diagnosis clear. As a rule, an examination of 
the rash alone is insufficient, and a diagnosis of erythema scarlatini- 
forme should not be made until the other exanthemata have been con- 
sidered and excluded. 

Treatment. — This depends entirely on the underlying cause or con- 
dition. Toxins present should be eliminated as rapidly as possible. 
The rash itself rarely calls for treatment. If there be itching or burn- 
ing sensations, a simple dusting-powder, with or without an anti- 
pruritic or a soothing lotion, may be used to make the patient more 
comfortable. 



ERYTHEMA PERNIO (PERNIO, "CHILBLAINS") 

Is a form of erythema occurring in persons having a feeble circulation 
or strumous diathesis, usually in the young and the very old. The 
redness is most conspicuous, as a rule, on the hands and feet, merely 
because of the distance of these organs from the centres of circulation. 
The redness is of either a light or a dusky shade ; is accompanied by 
tenderness, itching, and burning sensations, especially when the part is 
brought near an artificial source of heat ; and may be the origin of 
exudative and other affections of the skin, though the ulceration and 
sloughing which occur in extreme cases are really the results of freez- 
ing the organs rather than of simple exposure to cold when the circu- 
lation is impaired. 



ERYTHEMA INTERTRIGO. Ill 

The Diagnosis is readily made when it is observed that the redness 
disappears on pressure, and also that the parts are actually cool rather 
than hot, the coolness being appreciable by the touch. Not rarely 
they are both cool and moistened with sweat. Pernio may closely 
resemble an early stage of lupus erythematosus, but the latter does not 
vary regularly with the seasons as does pernio, which usually disap- 
pears in summer and reappears in winter. The two conditions are at 
times related, as individuals are seen with pernio of the hands or the 
feet, and lupus erythematosus of the face. Cases are recorded in which 
the site of a recurring pernio has become the seat of a typical lupus 
erythematosus. 

The Treatment of pernio should be directed to improvement of the 
circulation and the general health. Warm clothing to protect the af- 
fected parts together with active exercise may do much to prevent re- 
currence of the disease. Fowler's solution is considered a prophylactic 
if given in small doses at the beginning of cold weather. The local 
treatment is by brisk friction and stimulating lotions, such as camphor- 
ated soap-liniment ; acetous, spirituous, and vinous lotions ; or the use 
of the ordinary " bay rum " of the shops. Afterward the parts should 
be well dusted with boric acid, and bandaged or wrapped in cotton. 
The severer forms of the disease are considered under Dermatitis 
Calorica. 

ERYTHEMA INTERTRIGO 

Is a hypersemic condition of those cutaneous and muco-cutaneous sur- 
faces which are in constant apposition, and between which there is a 
hypersecretion or retention of sweat. 

Symptoms. — The erythema is limited to portions of the integument 
which lie in contact with each other, and is subject to certain modifica- 
tions. The sites of such contact in the human body are the axillae, the 
groins, the cleft between the nates, the intermammary and inframam- 
mary spaces in women, the superior and inner faces of the thighs, the 
scroto-femoral and the labio-femoral clefts in the sexes respectively, the 
flexures of the joints, and in especially obese individuals all those parts 
where the integument is thrown into fleshy folds, as about the necks of 
infants, and even over the crest of the ilia in fat women. In these 
localities the disorder, beginning as an erythema traumaticum, proceeds 
by its irritative effects to stimulate the secretion of sweat, which is 
freely poured out between the adjacent folds of the skin, and may there 
temporarily be imprisoned. The surface, heated and reddened, is also 
somewhat macerated by the effused perspiration, and the latter, when 
chemically altered, as it is frequently under these circumstances, adds 
still further to the original disorder. The ground is thus w 7 ell pre- 
pared for an exudative process, which not infrequently supervenes in 
the form of a dermatitis or an eczema marginatum ; but the disorder may 
be limited to mere hyperemia with hyperidrosis, and disappear before 
the supervention of actual inflammation. 

The sensations produced are those of heat and tenderness. When 
the parts in contact are separated the surfaces are seen to be reddened 
and chafed. Here and there very superficial abrasions of the macerated 
12 



1 78 1NFLA MM A TIONS. 

epidermis become evident. One such abrasion is always especially 
significant. It is the linear and superficial excoriation which marks 
the line of deepest contact of the two apposed surfaces of the skin at 
the bottom of the angle formed by the two. An offensive odor usually 
proceeds from the part in consequence of the secreted fluid. The secre- 
tions of an intertrigo stain, but do not stiffen, the linen of the patient, 
and they thus differ from the serous fluid poured out in an exudative 
dermatitis. 

Etiology. — The disease is chiefly induced by heat, friction, and 
moisture — these causes occasionally cooperating. The heat may merely 
be that of the natural temperature of the body, or it may be increased 
by that due to season and climate. The friction also may merely be 
that originating between the surfaces in apposition, or it may be in- 
creased by clothing or other articles worn next the skin. The moisture 
which produces maceration of the epidermis is that originating in the 
perspiratory follicles, their secretion being doubtless stimulated by the 
heat and friction. The interchange of operation of these three factors, 
lastly, is shown by the fact that friction, if severe, is capable of increas- 
ing the temperature of the part to which it is applied. 

As aggravating causes may be named other physiological secretions 
and excretions retained in contact with the surfaces affected with an 
intertrigo. Thus, the feces of the infant left in contact with its nates 
upon the napkin ; the urine of the old man with paralysis of the bladder 
or with "overflow" from prostatic disease ; the milk of nursing women 
dribbling over the breast to the inframammary region ; retained lochial, 
menstrual, and similar discharges, are all efficient in this regard, and 
are particularly liable to induce that form of dermatitis to which the 
intertrigo then plays a subordinate part. Fleshy and gouty persons 
chiefly suffer from these accidents. 

Diagnosis. — The recognition of a simple erythema intertrigo is a 
matter of no difficulty if regard be had to the exciting and aggravating 
causes enumerated above, and to the special localities in which such 
hyperemia generally originates. If an eczema or a dermatitis super- 
vene, the fact will appear from increased subjective sensation (usually 
severe itching), from an infiltration of the affected integument, and 
from the appearance of those lesions and discharges which are signifi- 
cant of these forms of inflammation of the skin. It must be remem- 
bered that transition from a simple erythema to a dermatitis of these 
regions is of frequent occurrence. Erythema intertrigo may occur as 
a mild form of eczema seborrhoeicum. 

The special sites of preference of intertrigo are those of the disease 
named by Hebra " eczema marginatum," or ringworm as it occurs upon 
the parts of the thighs covered by the "reinforcing" patch in the 
trowsers of cavalrymen. The disease is properly named "tinea cir- 
cinata cruris," though it is found also about the axillae, the buttocks, 
and the groins of both sexes. Here the disorder, however, is of the 
exudative type, and, moreover, is distinguished by a characteristic 
"festooning" of the elevated border marking the advancing limit of 
the disease. The microscope, by revealing the existence of a fungus, 
will, of course, put an end to any doubt. In intertrigo the most 



ERYTHEMA INTERTRIGO. 179 

marked evidence of disease is to be recognized in the deeper parts of 
the cleft between the two adjacent skin-surfaces, while in tinea cir- 
cinata cruris the growth of the parasite is most active at the advancing 
border of the patch, which is, moreover, perceptibly elevated above the 
sound skin. 

Treatment. — Intertrigo is an exceedingly common affection of the 
skin, and it occasionally proves of great annoyance to those suffering 
from it. The skill of the young practitioner is often tested early in his 
professional career by his management of such cases ; and not a little 
may depend upon the success with which he is rewarded. Gouty 
patients always require limitation of the diet, and often also medication 
with alkalies and mercurial cathartics. 

The affected surfaces should gently be cleansed by ablution with 
soap and warm water, and the offensive odor of the secretions remedied 
by the addition to the water of a weak solution of formalin, of carbolic 
acid, or of the dilute liquor sodse chlorinatse. The parts are then to be 
carefully dried with a freshly laundered towel or a soft handkerchief, 
and afterward one of the dusting-powders very thoroughly applied. 
To be of service, these powders must be impalpable, and, if compounded 
by a druggist, be sifted through fine silk bolting-cloth. The articles 
chiefly used for this purpose are zinc stearate with acetanilid, bismuth, 
starch, zinc oxide, French chalk, lycopodium, or, when an antipruritic 
effect is desired, camphor. Combinations of several of these are at 
times effective. The formula of McCall Anderson is highly esteemed: 



M. 



For the purpose of absorbing excessive perspiration magnesium 
carbonate is the most effective of all the powders. 

The following is the formula for a dusting-powder recommended 
by Klamann : * 

R Talc, venet. pulv., 

Acid, salicyl., 

Magnes. ust. subtil, pulv., 
Sig. Dusting-powder. 

Finely bolted starch answers well alone or in combination with some 
of the other articles above named. 2 

The affected surfaces of the skin must also be separated in order to 
prevent further friction. A thin strip of lint, antiseptic cotton, or 
medicated wool may be used for this purpose, and must be inserted as 
far as the deeper portions of the cleft in which the secretion chiefly 
forms. Occasionally it will be found useful to anoint this absorbent 
layer with cold-cream salve or with vaselin. Where an astringent effect 
is desired lycopodium or other dusting-powder may be compounded with 

1 Hebam. Kalend., Obstet, Gazette, March, 1882. 

2 Unna's salve-muslins and pastes will be found effectual and neat applications in 
many forms of intertrigo. 



R 


Zinci oxid. pulv., 


,^ss; 


16 




Camphorae pulv., 


3jss ; 


6 




Amyli pulv., 


Bj; 


32 


Sig. 


Anderson's dusting-powder. 







3v; 


20 




gr. "J ; 




18 


3jss ; 


6 


M 



180 INFLAMMATIONS. 

tannin, alum, or similar substances. The list of lotions also may at 
times be consulted with advantage. Thus, cologne-water, weak spirit 
lotions, tannin, or aromatic wine, or magnesium carbonate, may each be 
serviceable. Lastly, carron oil (equal parts of lime-water and linseed- 
oil), spread thickly upon linen, will possibly give more relief than other 
articles named, the chief objection to it being the consequent soiling of 
the patient's clothing. 



ERYTHEMA MULTIFORME. 

(Erythema Exsudativum Multiforme. Fr., Erytheme 
Papulo-tuberculeux.) 

Symptoms. — In this affection the most common lesions are erythem- 
atous maculae, flattened papula?, and even large flat nodosities. Vesi- 
cles and bullae occur in a few cases. While multiformity is the rule, 
one type of lesion usually predominates in each case. The eruption is 
nearly always symmetrical, and occurs usually upon portions of the 
extremities, the forearms, the legs, and the dorsum of the hands and 
feet. It occurs exceptionally on other parts of the body, and rarely 
upon the mucous membrane of the mouth, nose, and conjunctiva. It 
has been seen on the sclerotic. From the beginning the lesions are 
more or less flat, elevated, and ©edematous. The eruption, which is 
generally recognized in well-defined patches, usually begins with 
pinhead- to finger-nail-sized macules of a darkish-, bluish-, or purplish- 
red shade that lose their color under the pressure of the finger, and in 
the course of some hours exhibit tumefaction in various degrees, thus 
producing the papules, tubercles, and nodes already described. In 
many cases there is a remarkable tendency to a flattening and widening 
of the lesions to a point, when they closely resemble a floridly tinted 
condyloma. The disease may persist for but a few days, but in severer 
grades it lasts for several weeks or months. Recurrent attacks through 
a period of years are not uncommon. In the height of the exudative 
process there is usually an efflux of the coloring-matter of the blood 
into the skin which is the site of the several lesions, and thus are pro- 
duced the singular shades of reddish black, purple and red, blue and 
red, yellow and orange, black and blue, that are characteristic of 
simple bruises of the extremities when the injury has been sufficient 
to cause extravasation of blood. The lesions occur in various shapes, 
sizes, and shades, a number of names having been used to designate 
their several appearances, that require explanation though they are 
without practical value. 

The exanthem is peculiar in that it is especially likely to develop 
and recur in the spring and autumn, is not capable of being awakened 
to activity by external irritation solely, and is productive of rather 
insignificant subjective sensations (burning and smarting) as compared 
with other rashes of even less brilliant hue. 

Erythema Annulare ( or Circinatum) is characterized by a central 
depression and paling of color, and a peripheral extension of the ery- 
thematous patch in the form of a ring. 



PLATE II. 




Erythema Multiforme Cireinate-type. 



ERYTHEMA MULTIFORME. 181 

Erythema Figuratum occurs in gyrations formed by coalescence of 
two or more annular circles. 

Erythema Induratum is considered with the tuberculous affections of 
the skin. 

Erythema Marginatum is that form of the disease in which a dis- 
tinctly elevated and denned marginal band is left as the sequel of an 
erythematous patch. 

Erythema Papulatum (or Papulosum) and Erythema Tuberculatum 
(or Tuberculosum) are those forms in which occur lesions respectively 
of a papular or a tubercular type. 

Erythema Urticatum is that form in which there is severe itching, 
and, as a result, scratching of the lesions, with crusts of dark dried 
blood at the summit of each. The crust is surrounded by the light-red 
or bluish-red, flattened or elevated patch characteristic of the disease. 

Erythema Vesiculosum and Erythema Bullosum are exceptional forms 
in which the exudation is sufficient to raise the horny layer of the 
epidermis into larger or smaller serum-containing chambers, which may 
be, as regards the erythematous patch, of central or peripheral situation, 
and which may crown the summit of papule or tubercle. The fluid is 
usually removed by absorption, and is rarely set free by rupture of the 
vesicle or bleb. 

Erythema Iris (Herpes Iris, Hydroa Vesiculeux) is the result of suc- 
cessive erythematous centric lesions, which at times form several dif- 
erently shaded concentric rings. 

At the onset there appear one or several vesicles or vesico-papules, 
which pursue their rapid career in two or three days. Upon the hyper- 
semic ring Avhich surrounds these lesions a second and even a third and 
fourth circlet of similar lesions form, each pushing the areola further 
to the periphery of the patch. The older lesions are in full retrogres- 
sion, while the newer vesicles are in process of evolution ; and the red 
blush which surrounds the earlier lesions is undergoing color-changes 
from vivid to purple and paler hues, while the zone of the latest vesicles 
is assuming its intensest shade. The lesions are pinhead- to pea-sized, 
rather persistent and firm, and terminate more often by resolution than 
by rupture and crusting. The concentric and parti-colored rings may 
make up a single patch an inch or more in diameter, or several such 
patches may form upon the surface of the integument. In the latter 
case the central disk of some of the patches will be seen to be composed 
of confluent lesions. The subjective sensations produced are usually 
trifling;. 

Atypical forms occur in which the lesions are developed imperfectly 
from papules, and also in which, in consequence of an unusual exudation 
of serum, bullae appear. These may coalesce or be filled with blood ; 
or hematuria may result, with severe involvement of the mucous mem- 
brane of the lips, the tongue, the soft palate, and other parts of the 
mouth, ulceration rapidly ensuing. Cases with these complications 
should really be classified with the grave forms of pemphigus, to which 
they properly belong. 

Erythema Nodosum (Dermatitis Contusiformis ; Fr., Eryth- 
eme Noueux) is a form of erythema multiforme, regarded by several 



182 INFLAMMATIONS. 

authors as a distinct affection, in which the characteristic lesions are 
of the dimensions of semi-globular pea- to fist-sized tumors, pale red 
to livid blue in color, tender upon pressure, and exhibiting in their 
involution the variegations of hue already described. They occur 
chiefly upon the legs and dorsum of the feet, but also more rarely upon 
the trunk and the face. Though occasionally becoming so soft to the 
touch that fluctuation may seem to be present, they never terminate by 
suppuration. 

Unna lays stress in the distinction between this disease and erythema 
multiforme upon the fact that the lesions of erythema nodosum never 
widen concentrically, never produce bullae, and never exhibit annular 
vesicles. 

The nodose lesions occur most often in youth, in girls more often 
than in boys, with acute or subacute symptoms frequently with rheu- 
matoid pains and febrile temperatures. The oval or roundish, eryth- 
ematous or empurpled nodes, varying in size from that of a small nut 
to that of a pigeon's egg, are most often seen on the lower limbs, 
though they appear also on the thighs, the buttocks, and the fore- 
arms. They are usually tender on pressure, and often painful. They 
may disappear in a fortnight, but occasionally observe a stadium of 
six weeks' duration, forming and disappearing in crops. The petechial 
appearance of the spots where they have existed is that of the charac- 
teristic " black-and-blue " mark. By some authors this disease is 
recorded as associated with tuberculosis, an observation probably due 
to the fact that it appears so often among the poorly nourished and 
ill-housed. It unquestionably occurs most frequently in the spring 
and autumn, and is not infrequently associated with arthritis or a rheu- 
matic diathesis. Other causes cited are : malarial chills, temperature- 
changes, endocarditis, urethral irritation (blennorrhagic, instrumental), 
medicamentous ingesta, alcoholic excesses, and dentition (?). 

A number of medicaments, when ingested or externally employed, 
are capable of producing eruptions identical in appearance with the 
lesions of erythema multiforme. For descriptions of these the reader 
is referred to the sections devoted to Dermatitis Medicamentosa and 
Dermatitis Venenata. Quinine, arsenic, belladonna, chloral, salicylic 
acid, iodine and bromine compounds, and other substances are often 
responsible for these symptoms. 

The name " multiforme," given to this disease by Hebra, is justified 
by the singular diversity of lesions which it displays. These lesions 
are remarkable, not merely for their variety, but also for their occur- 
rence in such variety both simultaneously and successively, and for 
their rapid change from one type to another. 

The subjective symptoms, save in the urticarial form of the dis- 
ease, are usually of a trifling character. The slight sense of heat and 
burning awakened by the lesions is altogether out of proportion to 
the extent of their development. 

The symptoms, however, indicative of a general disturbance of the 
system may be of a marked character. General malaise, fever, inap- 
petence, pharyngeal inflammation, chills, severe gastro-intestinal dis- 



ERYTHEMA MULTIFORME. 183 

order, rheumatoid involvement of the articulations, and even organic 
changes in the heart (valves, endocardium, and pericardium), lungs, 
and kidneys have all been noted as coincident or as causative phe- 
nomena. In many of these cases it is clear that the exanthem belongs 
to the list of symptomatic erythemata, and that it is of insignificance 
in comparison with the grave general condition. It may thus be the 
precursor of typhoid fever, malaria, or severe articular rheumatism, or 
may become even an abortive expression of these disorders. With 
these exceptions, however, the prognosis is in general favorable, as the 
disease may terminate in a few days, and rarely exceeds a month in 
duration. 

Occasionally the mucous membranes are affected to a disagreeable or 
even painful extent. Thus, a sudden tumefaction of the uvula may 
supervene upon the cutaneous symptoms, in cases sufficient to impede 
respiration ; or the lining membrane of the larynx may be involved, 
and the resulting aphonia in various degrees persist for two or three 
days. 

Etiology. — The affection is commonest in the spring and autumn ; 
it occurs in the young or in the early periods of adult life ; the papular 
and tubercular forms are more common in men, and the nodose forms 
in women ; many patients are affected with rheumatism. In two valu- 
able contributions to the study of the visceral complications of the 
erythema group Osier * has shown that the cutaneous symptoms may 
be merely surface-expressions of a visceral disorder ; and indeed that 
the skin-symptoms may wholly be absent when the disease is in prog- 
ress. In the eighteen cases studied by him there were three sets of 
symptoms: (a) polymorphous skin-lesions, including acute circum- 
scribed oedema, urticaria, purpura, and ordinary forms of erythema 
multiforme ; (b) visceral lesions, including (1) gastro-intestinal crises 
in which severe colic, with or Avithout vomiting, diarrhoea, or bloody 
stools, was frequent, (2) hseniaturia and nephritis, (3) hemorrhages from 
mucous surfaces, (4) cerebral symptoms, (5) pulmonary complications ; 
and (c) infiltration of synovial sheaths and periarticular tissues, and 
arthritis. In some of his cases a given visceral lesion had been accom- 
panied at different times in the same individual by each of the types 
of cutaneous lesions. 

The etiology of erthema multiforme includes a list of varying and. 
widely differing causes. Among the concurrent disorders may be 
named: cardiac affections, diphtheria, toxaemias, and neurotic disturb- 
ances. Severe manifestations of the disease have been observed in a 
young woman with extensive ulceration of the cervix uteri. Tilbury 
Fox noted a frequency of symptoms in young servants brought to town 
from the country. It is not rare in young female immigrants who 
have recently made a "steerage" passage to America. Mackenzie 2 has 
called attention to the relationship of erythema multiforme to rheuma- 
tism and to purpura rheumatica. 

There can be little doubt that erythema multiforme, arthritic pur- 
pura, urticaria, and acute circumscribed oedema are closely related. 

1 Amer. Jour. Med. Sci., December, 1895 ; and Brit. Jour, of Derm., July, 1900. 

2 Brit. Jour, of Derm., April, 1896. 



184 INFLAMMATIONS. 

The reasons for such belief, as stated by Osier, are : the similarity 
of conditions under which these disorders occur, the identity of the 
visceral manifestations, and the substitution of these affections for each 
other in one and the same patient at different times. 

Pathology. — Erythema multiforme is essentially a hypersemia of 
the integument that, under certain obscure influences, advances more 
or less rapidly to the stage of a mild grade of inflammation with conse- 
quent exudation. If, with Landois and Lewis, it be accepted that 
the process is the result of vasomotor nerve influence, it cannot be 
determined whether these nerves are irritated at their points of origin 
or of distribution. In the case of erythema nodosum Hebra advanced 
the hypothesis that the morbid process is essentially an inflammation 
of the lymphatic vessels. In some cases it is evident that there is 
extravasation of blood from the vessels into the skin of the affected 
part. 

Leloir 1 discovered in the papules, tubercles, and bullae of erythema 
multiforme only the phenomena of hypersemia and exudation limited 
to the corium and subcutaneous tissue; and Villemin 2 simply confirms 
these facts. Singer 3 has shown that the skin-lesions in erythema multi- 
forme are for the most part evidences of staphylococci and strepto- 
cocci in the blood. Crocker, examining a patch of erythema tuber- 
culatum, recognized merely a cell-effusion in the upper portion of the 
corium extending sparsely below, and then chiefly along the ducts and 
follicles. There was slight rete-proliferation. Unna recognizes both 
in erythema multiforme and erythema nodosum : vascular dilatation, 
cell-proliferation especially around the vessel-walls with cell-emigra- 
tion, and oedema of the cutis. In two cases of the iris-type Pardee 4 
found simply an acute exudative inflammation of the upper part of the 
corium. 

There is evidently a toxin responsible for these changes, the nature 
of which has not been determined. 

Diagnosis. — Erythema multiforme is always to be carefully distin- 
guished from the traumatism producing braises, especially upon the 
lower extremities. This point may have an interesting bearing 
upon certain medico-legal questions, especially in the case of young 
children. 

The tendency of the disease here considered to symmetrical arrange- 
ment upon the two sides of the body, the occurrence of lesions evi- 
dently dating from several periods in which successive crops appear, 
and the absence of all history of external injury, will usually suffice to 
establish a diagnosis. Among the precocious affections of the subcu- 
taneous connective tissue in syphilis Mauriac described a lesion re- 
sembling somewhat the symptoms of erythema nodosum ; but in such 
cases, and especially in women, mucous patches of the vulva, of the anus, 
or of the mouth, with coincident adenopathy, Avould point to the real 
nature of the disease. Syphilitic nodes and gummata are distinguished 

^ull. de la Soc. an at., 1884, p. 294. 
2 Gaz. hebdom., 1886, Nos. 22 and 23. - 
3 Wien. klin. Woch., 1897, 38. 
* Johns Hopkins Hosp. Bull., July, 1898. 



ERYTHEMA MULTIFORME. 185 

from the lesions of the nodose forms of erythema by the pain attending 
the former, their fewness, their overlying integument untinted save 
when actually softening and approaching disintegration, their obvi- 
ously subcutaneous site, and the usual concomitant symptoms of late 
lues. 

The chief points by which a diagnosis of the erythemata in general 
is established are : the recognition of the vivid coloring of most of the 
lesions ; their oedematous character ; their symmetry as a rule ; the pig- 
mentation following those situated on the lower limbs ; their frequent 
association with rheumatism or rheumatoid pains, febrile phenomena, 
malaise, or other constitutional disturbances. The wheals of urticaria 
are smaller, more whitish centrally, more closely packed together, less 
symmetrical, rarely grouped, and, as a rule, decidedly more acute than 
those of erythema. Cases difficult to assign to either disease are com- 
mon, and an error in either direction is not serious. Rubella (German 
measles) is to be distinguished by its adenopathy, its pharyngeal symp- 
toms, and its flattish spots. In eczema erythematosum there is less 
definition of each patch, and the redness is commonly diffuse ; papular 
forms of eczema are usually commingled with other readily distin- 
guished symptoms of that disease. 

Potassium iodide and a few other drugs administered internally are 
capable of producing almost every one of the lesions described above. 
In the erythemata for which iodine and bromine salts have been admin- 
istered, with the production of skin-symptoms, the confusion produced 
becomes a fruitful source of error. 

Treatment. — As in the majority of instances the disease under con- 
sideration progresses naturally to a favorable termination within the 
course of a few weeks, the duty of the physician is usually limited to the 
question of diagnosis and to a study of the etiology in each case, with 
the purpose of preventing future attacks. He should remember that 
the larger lesions seen in erythema nodosum never suppurate, and thus 
should not be tempted to open them with a lancet. Local treatment is 
often unnecessary. For the relief of the slight burning or itching present 
in some cases a dusting-powder, sedative or antipruritic lotion, or other 
protective dressing may be employed. Bullae and vesicles should be 
evacuated and protected with a simple antiseptic dressing. Internally 
such medication should be employed as is indicated by the general 
condition of the patient. Iron, quinine, the salicylates, salol, strych- 
nine, and dilute hydrochloric acid will be found beneficial in many 
cases. Constipation and indigestion are to be corrected by appro- 
priate measures. When the disorder accompanies rheumatic or other 
systemic disease internal treatment is to be directed to the general 
condition present. When the erythema produces extensive oedema 
of the uvula incisions may be requisite to prevent dyspnoea and 
dysphagia. 

Prognosis. — It will be gathered from what has preceded that the 
prognosis is usually favorable, but necessarily varies with the constitu- 
tional disease of which the erythema may be a mere symptom. The 
malady may relapse in susceptible individuals at those periods of the 
year when it is most frequently observed. 



186 INFLAMMA TIONS. 

PELLAGRA. 

(Lat. pellis, the skin ; ceger, diseased.) 

(Lombaedy Erysipelas, Lombabdy Lepbosy, Risipola Lom- 
babda, La Rosa, Mal Roxo.) 

This disease has attracted attention by its extensive ravages in Lom- 
bardy and the contiguous provinces, including a portion of Southern 
Egypt, France, and Spain. It is a constitutional epidemic disorder, 
accompanied by an exanthem which justifies its brief consideration in 
this connection. 

Symptoms. — The earliest symptoms of the disease, usually first 
noted in the spring, are prodromic, and characterized by marked fatigue, 
malaise, and occasionally by febrile symptoms. Soon the face, neck, 
chest, backs of the hands, and forearms (when exposed to the sun) 
are affected with a symmetrical erythema of a dull lurid hue, disap- 
pearing on pressure, which may be accompanied by desquamation, 
occurring in successive years chiefly in the summer season, often fading 
in the autumn, at times with desquamation. After frequent relapses 
the skin becomes of a dark olive-brown, bluish-red, or deeply pigmented 
and bronzed hue, and general exfoliation of the epidermis follows in 
large flakes. Simultaneously, an extraordinary degree of muscular 
feebleness is noticed ; the skin becomes at first pruritic or hypersesthetic ; 
later, distinct atrophy occurs; and a sensation of chilliness is induced, 
similar to that observed in general exfoliative dermatitis. As in that 
disease also, the fingers gradually become semiflexed into the palm, and 
gastro-intestinal derangements supervene, accompanied by a furred 
tongue, inappetence, colicky pains, and diarrhoea. Disorders of the 
nervous system are betrayed by melancholia, disturbed vision, idiocy, 
convulsions, and symptoms of meningitis. Post mortem, pachymenin- 
gitis, with induration, atrophy, and other secondary changes in the 
brain and cord, have been observed. 

The erythema displayed is one corresponding largely with that of the 
other symptomatic erythemata. Its colors are in different hues according 
to the age and sex of the patient and the stage of the disease. It disap- 
pears under pressure at first ; later it may persist even before the pig- 
mented condition is produced ; it may be of congestive type and accom- 
panied by bullous efflorescence and crusting with erosive features. It 
may subside in a fortnight not to return, or return with successive sea- 
sons till the integument becomes gradually wrinkled, thinned, and in 
the xerodermatous state of impoverished senility. 

After the eruptive symptoms the important features are : the mus- 
cular feebleness, the remarkable tendency to chills alternating with 
febrile accesses, the flexion, more or less persistent, of the fingers into 
the palms, and, in fatal cases, changes in the nervous centres, such as 
pachymeningitis and sclerosis of nerve-tissue, producing during the life 
of the patient paralytic and paretic symptoms, melancholia, imbecility, 
and dementia. 

Etiology and Pathology. — Pellagra originates in the use, as an 



PELLAGRA. 187 

article of diet, of maize which has been improperly dried or has devel- 
oped deleterious substances after its reduction to a coarse powder. 
Lombroso 1 has produced the symptoms of the disease experimentally ; 
and has demonstrated as etiological factors toxins developed during the 
spoiling of maize, though numerous mycotic and parasitic organisms 
are also present during the process, pure cultures of which produce no 
symptoms of the malady. In 113 autopsies, of which 70 were made 
by himself, Lombroso discovered: exudation into the membranes of 
the cord, liver, kidneys, and spleen ; atrophy of viscera supplied by 
the vagus : fatty degeneration of kidneys, liver, myocardium, and ves- 
sels and cells of the cord; pigment-changes in cells of brain, cord, 
liver, kidneys, and heart; atheroma, calvities, dermato-sclerosis, and 
sclerosis of cord. Individuals have suffered from the disease, it is true, 
who never partook of maize, and also those who were not specially 
exposed to the action of the sun, which in some cases seems to have 
served as an aggravation of the malady. The wretchedness, poverty, 
poor food, and moral and social condition of the inhabitants of pel- 
lagrous districts, many of them toiling under a burning sun, half- 
starved, emaciated, and despairing, explain in part only the symptoms 
of the scourge which afflicts them. 

The distinction between pellagra and pseudo-pellagra has an etio- 
logical basis : one class of patients suffering from classical symptoms 
solely produced by the specific toxins of the disease ; the other class 
debilitated by alcoholism, malaria, uraemia, and other morbific factors. 
In cachectic men and women who have never been exposed to the sun 
and have not been known to be poisoned by eating decomposed or fer- 
mented maize, the symptoms of pellagra have been noted ; while in 
others mere exposure to the rays of the sun of the cachectic and of 
those suffering from visceral maladies (gastric carcinoma, disease of the 
suprarenal capsules, etc.) has not produced characteristic lesions of 
pellagra. 

The Treatment is by prophylaxis ; improvement of the hygienic 
and climatic conditions of the patient ; quinine and tonics in cases of 
debility; proper management of nervous and gastric troubles; and, 
when practicable, a generous dietary. Lombroso recommends, as a 
prophylactic measure, care in the storing of grain. 

The Prognosis is favorable in some cases, which may be so mild as 
to be scarcely noticeable ; in others it is grave ; and in districts where 
the disease prevails extensively the mortality may be formidable. 

Acrodynia (Epidemic Erythema) is an affection suggesting in 
its symptoms those of pellagra. It first occurred in Paris, in the year 
1828, in an infirmary for aged men; and has been since recognized in 
epidemic form in France, Belgium, Algiers, Mexico, and a few other 
countries. 

The disease begins with facial oedema, gastric distress, conjunctival 
injection, and hyperaesthetic symptoms, with a sense of formication and 
pricking in the parts chiefly affected. The cutaneous lesions are ery- 
thematous, displayed in points over the extremities, and especially over 

1 Die Lehre v. d. Pellagra. Coblentz, Berlin, 1898. 



188 INFLAMMATIONS. 

the hands and the feet, particularly their palmar and plantar sur- 
faces. It has either a simple or a polymorphic expression, and is 
concluded by a furfuraceous or lamellated desquamation. When fluid- 
containing lesions are produced, these are either vesicular or bullous, 
and filled with limpid or reddish contents. When the consequent 
exfoliation occurs over the palmar and plantar surfaces there may be a 
desquamation similar to that occurring in some of the exfoliating der- 
matoses, large horny flakes and casts being either firmly adherent to, 
or separable from, the tissues beneath. 

The grave complications of cases are : oedema followed by atrophy, 
paretic symptoms, febrile and gastric complications, and senile ma- 
rasmus. 

One of the most characteristic features of the disorder is the blackish 
hue of the skin of affected persons over the breasts, belly, flanks, chest, 
axillae, and inguinal regions. 

The Pathology is obscure ; the Treatment, that indicated by the 
general ill-health of the patients ; and the Prognosis, unfavorable. 

URTICARIA. 

( Lat. urtiea, the nettle.) 

(Hives, Nettle-rash. Fr., Urticaire ; Ger., Nesselsttch, 

Nesselfieber.) 

Symptoms. — This disorder may be ushered in by constitutional 
symptoms, such as inappetence, malaise, cephalalgia, or mild pyrexic 
phenomena lasting for a few hours or even a day or more. 

With, and often without, such prodromic symptoms the eruption 
suddenly appears in the form of wheals upon the skin-surface, that 
frequently disappear with equal rapidity, leaving no traces of their 
existence save a slight and transitory hypersemia of the affected spot. 
The lesions may be as small as a finger-nail or a coffee-bean, and usually 
are of this size; but in rare instances " giant "-wheals are seen — large 
tomato-sized projections or flat elevations of broad areas of the integu- 
ment, that cover the greater part of the belly or buttock. In color 
the lesions are rosy red or whitish, and are usually surrounded by 
a hypersemic areola. They may be isolated and few, or be numerous 
and closely packed together ; they may even coalesce, so that individual 
wheals are scarcely recognizable. They are usually firm and semisolid 
to the touch. Rarely, the horny layer of the skin is raised in fluid- 
containing lesions by the sudden effusion of serum beneath. In contour 
they are roundish or oval-shaped, but a variety of curious outlines may 
result from the irregularity of their development. Concentric circles, 
lines, bands, and even figures are in this way produced. The finger- 
nail drawn across the unaffected portions of the skin of a patient with 
urticaria will often produce a linear wheal ("urticarial autogram") of 
extent corresponding with the line of irritation (dermographism). In 
this way the so-called " medium " with a sensitive skin exhibits written 
characters upon the surface of his body. 

The subjective sensations induced by these lesions are distressing 



URTICARIA. 189 

in varying degrees, according to the susceptibility of the individual. 
Every grade of pruritic burning, tickling, crawling, pricking, and 
especially stinging sensations, is thus engendered. The efforts of the 
patient to secure relief by scratching not only serve still further to 
develop the eruption, but also to irritate, tear, and otherwise wound 
the lesions already in full evolution. In this way serous effusions are 
produced at the summits of the wheals ; and in this way, also, lesions 
really transitory in their course may be changed to more persistent, 
deeply colored, flat, lenticular papules. Where the skin is delicate 
and thin, as is that of the lids and prepuce, considerable oedema may 
result. 

All parts of the body may become affected, irrespective of age and 
sex, though children are particularly liable to the disease. There are 
few very young children with skins unwashed for an entire month 

Fig. 40. 

■■■■HHHHttHm 



Autographism in urticaria. 

who will not exhibit urticarial symptoms if there be an added irrita- 
tion of the surface. The disease occasionally involves the mucous 
membrane of the mouth, pharynx, and larynx. 

The lesions numerically may be few or be so numerous as to cover 
the entire surface of the body. Though more frequently acute in 
course, they often recur from apparently insignificant causes, or even 
become chronic. In many cases trivial the disease may become so 
aggravated as to make the largest demands upon the skill of the 
physician. 

The rapidity of appearance and disappearance of the lesions visible 
upon the skin is a characteristic feature of the disease. In some 
instances but a few moments are required after the operation of an 
efficient cause to develop a large number of closely packed wheals. 
Even while they are under inspection it can be noted that there is a 
change in individual lesions, some fading or completely disappearing, 
while others are newly developing. 

A number of names have been employed to designate the several 
external peculiarities of the lesions as they are presented to the eye. 
Thus, Urticaria annularis occurs in rings ; U. figurata, in gyrations 
from union of several lesions or patches of lesions ; U. vesiculosa and 
U. bullosa, where there is a vesicular or bullous development at the 
summit of the lesion ; U. papulosa (or Lichen urticatus), where there 



190 INFLAMMA TIONS. 

is a combination of the features of the wheal and the papule, the 
lesions being naturally grape-seed- to coffee-bean-sized, and covered 
with blood-crusts where their apices have been torn in scratching ; 
U. tuberosa, where "giant "-wheals occur, some attaining the size of 
a hen's egg ; U. hemorrhagica (Purpura urticata), where the urticarial 
element is developed in a lesion produced by cutaneous hemorrhage ; 
and U. evanida, or perstans, where there is, respectively, a rapid or a 
slow process of involution in the characteristic symptoms. 

Baker l reported a case of Urticaria Tuberosa characterized by 
the presence in various parts of the body of persistent yellowish-red 
tubercles, which proceeded to ulceration. The parts most affected were 
the knuckles, the elbows, and the ear. These tubercles are said to 
have begun in a manner similar to that which characterizes the onset 
of evanescent urticarial wheals and tubercles. A somewhat similar 
case was observed by McCall Anderson. 2 

Urticaria, like erythema, may be either idiopathic or symptomatic ; 
and in each form the urticarial conditions may underlie or be superim- 
posed upon almost every elementary lesion noted in the integument. 
The wheal may complicate (or be complicated by) the macule, papule, 
tubercle, vesicle, bulla, and pustule. It may spring from an excoria- 
tion or may result in a fissure. It is common in traumatisms, and is a 
prominent symptom in the skin bitten by insects, reptiles, or domestic 
animals. 

Etiology. — Idiopathic urticaria always results from the action of 
external irritants, prominent among which are the bites or stings of 
mosquitoes, lice, fleas, bedbugs, gnats, wasps, caterpillars, and bees. 
The irritant action of the nettle ( Urtica urens and U. dioica) has given 
the malady its name. Contact with certain species of the jelly-fish is 
also effective. The wounds thus inflicted usually give rise to a stinging 
or a burning sensation, by which the patient is excited to rub or scratch 
the part. A wheal is rapidly formed at the site of the injury, and the 
irritation set up is conveyed to other parts of the skin in the vicinity, 
so that, especially in children, a single traumatism by an insect may 
excite an urticaria covering a much larger area. Many medicaments 
operate similarly, and it should be added that all the external agencies 
which are capable of irritating the skin, though applied without toxic 
effect to the mass of men, may produce urticaria in individuals predis- 
posed to the disease, or having a peculiar intolerance for a particular 
substance. Thus, a common flaxseed poultice when made to cover but 
a small portion of the body has produced violent symptoms of urticaria. 
Climatic influences, more particularly those in which the surface of the 
body is exposed to cold air, are efficient in the production of urti- 
caria, as also of bronchial asthma, with the symptoms of which the 
disease under consideration, in the case of adults, may often coexist or 
alternate. Mechanical violence, the application of leeches to the skin- 
surface, and surgical traumatisms may also act as exciting causes. 

Symptomatic urticaria is chiefly of the variety named by authors 
ab ingestis, since it most frequently results from medicinal or from 



1 Lancet, August, 1881, p. 153. 

2 Brit. Med. Jour., December 8, 1883, 






URTICARIA. 191 

dietary articles taken into the stomach. Of the latter class may be 
named eggs, cheese, pork, sausage, coffee, tea, cocoa, confectionery, 
crabs, lobsters, clams, caviar (and several species of fish-roe), oysters, 
and fish generally, strawberries, cucumbers, skins of grapes, nuts, 
dates, raisins, almonds, figs, prunes, gooseberries, raspberries, canned 
(" tinned ") fruits, meats, vegetables, oatmeal, pease, beans, onions, 
garlic, " corn," pickles, sauces, honey, mushrooms, pastry, salads, and 
spinach. Vinegar, champagne, beer, and alcoholic beverages in gen- 
eral are capable of inducing a similar effect. 

Among the medicinal articles capable of inducing urticaria may be 
named the balsams, the turpentines, quinine, glycerin, chloral, valerian, 
arsenic, hyoscyamus, cinchonidine, salicylic acid and the salicylates, 
senna, santonin, and opium and its alkaloids. 

In the case of children and infants a severe urticarial efflorescence 
may be provoked by worms, or by any undigested morsel of food, 
or indigestible material of any sort that may have been passed into 
the stomach. Thus, a bit of orange-peel or a fragment of potato- 
paring or the skins of grapes may be discovered to lie at the root 
of the trouble. In the case of adults, also, who have experienced 
repeated attacks of urticaria, and suffer from sensitiveness of the gastro- 
intestinal tract, any food not easily digested by a given individual may 
induce in him a return of the disagreeable symptoms. 

This undue sensitiveness to the effect of ingesta or of external irri- 
tants is often an idiosyncrasy peculiar to the individual either on special 
occasions or at all times, and, given this susceptibility, the effect is 
often great with a relatively insignificant etiological factor. Thus, a 
teaspoonful of beer, one grain of quinine, the smallest fragment of 
cheese, or but a single strawberry, may not only induce an urticarial 
rash of such extent as to cover the greater part of the surface of the 
body, but will also do the same on every occasion when the articles 

I named are swallowed in the quantities given. The fact that a small 
quantity of the article ingested can produce urticaria is important, 
because it emphasizes the general characteristics of the medicamentous 
eruptions. The a priori reasoning, that the greater the quantity of 

| the toxic agent applied or swallowed, the graver the effect, may lead 

1 to gross errors. It should be remembered, in seeking the explanation 
for an urticarial rash, that the smallest amount of apparently innocent 
substances may be responsible for the largest annoyance. In excep- 
tional cases the mere odors of iodoform, linseed, liquorice, certain 
plants, etc., have been sufficient to cause an attack of urticaria. 

Other causes of urticaria may be cited, such as moral emotions (fear, 
shame, anger) ; pulmonary diseases, especially asthma ; gastro-intestinal 
disorders, in which ingesta play no part ; intestinal parasites ; malaria ; 

I the exanthematous fevers, particularly in their prodromal stages ; dis- 
orders of the uterus, the kidneys, and the nervous centres; pregnancy, 
dentition, and the irregularities attending the menopause ; and, lastly, 
the following special diseases: pemphigus, prurigo (of Hebra), rheu- 

' matism, and purpura. 

The close affinity of urticaria with acute circumscribed oedema, pur- 
pura, and erythema multiforme is discussed with the last-named disease. 



192 INFLAMMATIONS. 

Pathology. — Urticaria is undoubtedly a vasomotor neurosis. The 
wheal is a sharply circumscribed oedema, and is produced apparently by 
an interchange of play between blood-vessels, muscles, nerves, and tis- 
sue, under the operation of a principle which the French term choc en 
retour. There is, first, most probably under the influence of the vaso- 
motor nerves, a clonic spasm of the capillaries in a limited area of the 
derma, by which is produced an acute oedema with some serous exuda- 
tion. The rapidity with which this clonus occurs is greater than that 
with which the tissues of the vicinage can accommodate themselves to 
it, either by imbibition or more diffuse tumefaction, and there results a 
counterpressure upon the affected capillaries, by which their lumen is 
still further restricted. As the wheal is not a purely fluid-containing 
nor yet an entirely solid lesion, but is semifluid in consistency, the 
mechanical pressure is greatest at its centre and least at its periphery. 
Thus are explained the white and relatively bloodless appearance of the 
centre of certain wheals, and their rosy or reddened outer border. 
The explanation is strengthened by the fact that generally the most 
acute lesions, those springing into view most rapidly, are chiefly char- 
acterized by this whitened centre, while those more indolent or even 
chronic in their career, having been less subject to the interplay of the 
forces described above, permit of more general vascular injection, and 
have a light-crimson or even at times a dull-red centre. Wheals have 
been excised and microscopically examined by Neumann, Vidal, Pon- 
cet, Unna, and others, with the result of discovering merely evidences 
of dilatation and engorgement of blood- and lymph-vessels. The deep 
vascular net shows the greatest dilatation of the lymph-channels. The 
compression of the blood- capillaries produces the w T hiteness of the 
acutely developed wheal. According to Poncet, the lymph-vessels 
are also choked with " lymph-clots." Rohe l explains the occurrence 
of the wheal by supposing that certain sensitive nerve-fibres of the skin 
possess also a vasomotor function. 

Unna believes the wheal is produced by a spastic contraction of the 
veins. Gilchrist 2 found in the lesions of urticaria factitia of but a 
few T minutes' duration an increase in the number of round cells and 
of polymorphonuclear leucocytes, and other evidences of true inflam- 
mation. 

Diagnosis. — The diagnosis of classical urticaria is so readily made 
that the disease is often recognized before the attention of a physician 
is called to it. As usual, the atypical cases are those in which con- 
fusion may arise. The chief points to be remembered are : the rapid- 
ity of evolution of symptoms, their ephemeral duration, and the char- 
acteristic sensations they awaken. The action cf the animal parasites 
and of insects not parasitic should not be overlooked, and the rash be 
closely examined for the minute wounds inflicted in this way, often 
covered with a minute pin-point- to pinhead-sized dried " blood-scale," 
and usually found in groups of two, three, or more lesions. The 
various forms of erythema papulatum, tuberculatum, and nodosum 
are liable to be mistaken for urticaria ; but this is in many cases inev- 

1 Maryland Med. Jour., May 15, 1881. 

2 Johns Hopkins Hosp. Bull., July, 1896. 



URTICARIA. 193 

itable, as intermediate forms between the two disorders are with diffi- 
culty assigned to either category. Absence of marked subjective sen- 
sations and persistence of lesions would generally point to an erythema, 
while marked prevalence of these symptoms would probably decide in 
favor of urticarial disease. 

In many cases the physician is consulted by a patient who gives a 
history of well-nigh intolerable distress at night or at other capri- 
ciously selected hours, and who repeatedly and vainly endeavors to 
exhibit the lesions as they appear upon the skin. Being examined on 
various occasions, scarcely a trace of cutaneous disorder is manifest. 
Here the practitioner has actually to decide upon the character of an 
eruption he never sees ; the task is rarely difficult, no other than the 
urticarial eruption behaving in this fashion. Occasionally the physi- 
cian Avill discover delicate, rosy or deeper stained mottlings of the 
skin-surface where the wheals have been. At times also he will suc- 
ceed, on the flexor aspect of the forearm, or in some situation in which 
the skin is equally delicate, in producing the appearance of one or 
more typical lesions by the aid of his finger-nail in scratching, or by 
rubbing. These cases are more frequently of the chronic or at least 
of the relapsing class, and the victims of the disease may have a char- 
acteristic facies, a worn look from loss of sleep or from mental emo- 
tion. In this class are often those who are mourning the death of 
relatives, the loss of property, or separation from home and friends, 
and those harassed by anxieties. 

The several lesions of erythema are larger than those of urticaria, and 
they do not develop from characteristic wheals ; in erythema multiforme 
the lesions are far more persistent in type and do not provoke the char- 
acteristic subjective sensations of urticaria ; in erysipelas the redness is 
characteristic and the swelling more diffuse. 

Treatment. — Many cases of acute urticaria demand no treatment. 
The physician is summoned for a diagnosis. The patient and his 
friends are alarmed by the dread of variola or other severe affection, 
and learning that perhaps a pickled cucumber is alone responsible for 
the disorder, they wait with equanimity for the favorable conclusion 
which is always reached. Fortunately, the unusual, severe, and 
relapsing forms rarely begin with acute symptoms. 

Naturally, the first indication to be observed is the removal of the 
cause, and with this, if possible, accomplished, the next is the exclusion 
of all aggravating agencies. The discovery of the cause, at times 
readily effected, is often the most serious problem presented. An 
exhaustive and minute examination of the person and the history of the 
patient, a study of his food, drink, medicine, regime, clothing, sleep- 
ing-apartment, habits, occupations of life, and mental state, are here 
essential. When the disorder is recent, and is an urticaria ab ingestis, 
a brisk emetic or a cathartic may rid the stomach or the bowels of 
offending matters. This done, it should be borne in mind that an 
idiosyncrasy of the patient may at this moment render the skin pecu- 
liarly sensitive to the action of other ingesta, and the diet, for a few 
days certainly, should be prescribed carefully. In many cases the 
alkalies are indicated by an acid condition of the stomach, and then the 

13 



194 INFLAMMATIONS. 

preparations of sodium, potassium, or magnesium are useful. Laxa- 
tives, such as rhubarb, magnesia, the cathartic mineral waters, and, in 
the case of children, small doses of castor-oil are frequently indicated 
when there is no suspicion of irritating ingesta. At other times there 
is marked atony of the digestive organs, when the mineral acids, the 
bitters, and the ferruginous tonics may be needed. Again, lactopeptin, 
pepsin, or bismuth subcarbonate or subnitrate may be exhibited with 
advantage for the relief of the indigestion which may be the promi- 
nent feature of the attack. 

Other remedies found useful in the internal treatment of urticaria 
are sulphurous acid in 1 drachm (4.) doses three times daily in sweet- 
ened water (Da Costa) ; copaiba ; sodium nitrite (J. P. Sawyer) ; strych- 
nine (Guibout) ; sodium arseniate, employed by Blondeau in doses of 
from 3V (0.002) to ^ (0.0013) of a grain ; the fluid extract of ergot 
in -J drachm (2.) doses (Morrow) ; atropine sulphate in doses of -g 1 ^ 
(0.001) of a grain (Schwimmer) ; and sodium salicylate in scruple 
(1.33) doses. The latter drug has been praised highly by a number of 
writers. It is often given in 1 grain (0.06) doses every hour. Pilo- 
carpine, or the fluid extract of jaborandi, is known to produce at times 
a powerful effect in relieving surface-congestions of the skin by means 
of the hyperidrosis it occasions, and in proportion to which it is pro- 
duced the drug may become dangerous. 

Schwimmer endorses the following formula for this affection : 



R. Atropinae sulph., gr. ^ ; 

Glycerin., I .. _ . „ 

Aq. dest., J aa 3 ss , l 

Gum. tragacanth., q. s. 

Ft. pil. No. xx. 



01 

M. 



The treatment of symptomatic urticaria should have regard also to 
that disorder of the viscera or of the general system to which the 
cutaneous symptoms may be attributed. Gout, as a not infrequent 
cause of the disease, should not be forgotten in advising treatment. 
The uterine complaint of a woman may require appropriate manage- 
ment, as also the diabetes of a patient with an affection of the kidneys. 
Quinine is indicated, of course, in periodical attacks, but its action in 
exceptional cases as a direct cause of urticaria should not be over- 
looked; the same, to a greater extent, is true of arsenic, potassium 
bromide and iodide, chloral hydrate, and gelsemium. The larger number 
of patients are best treated without the employment of these drugs. 

In the local treatment of urticaria protection of the sensitive skin 
from all sources of external irritation is the chief object. The complete 
covering of an affected region with wadding will often cause a rapid 
disappearance of the symptoms. Individual lesions which are sealed 
with collodion or plaster usually disappear promptly. The zinc-oxide 
adhesive plaster is very serviceable, as it does not irritate the skin. 
The patient's underclothing should be of soft linen, cotton, or silk, and 
to prevent friction Avith the skin a dusting-powder may be used freely, 
both on the skin and in the meshes of the underwear. Sleep should be 
secured without an excess of bed-covering, and places where the temper- 



URTICARIA. 195 

ature is for any reason elevated should be carefully avoided by the 
patient, such as proximity to a fireplace or a droplight, heated places of 
amusement, the kitchen, etc. 

Great diversity exists in the methods employed to assuage the 
disagreeable sensations experienced in the skin. This diversity is 
explained by the varying results obtained in different patients after the 
application of the same medicinal agent. Thus, cold and hot water- 
baths, baths medicated by marine salt, aromatic vinegar, alcohol, cologne, 
camphor, the alkalies, and sulphuric ether (compresses dipped in such 
solutions and laid over the part affected), douches, and vapor-baths will, 
any of them, in the case of some individuals, produce a marked allevi- 
ation of symptoms, and in others will be either inoperative or actually 
serve to aggravate the symptoms in the highest degree. Hebra asserts 
that several of the baths named above are useless, while Kaposi recom- 
mends cold lotions medicated with aromatic volatile substances. Fox 
prefers that alcohol, or cologne-water to which benzoic acid has been 
added, be dabbed over the part and permitted to evaporate. Solutions 
of menthol in alcohol and water, 1 part to 500 or 600, operate simi- 
larly. Hillairet and Gaucher employ in a similar way a solution con- 
sisting of one-third of ether and two-thirds of warm water. 

The alkaline bath should contain sodium carbonate, sodium biborate, 
alum, or potassium bicarbonate, either singly or in combination in the 
strength of about 6 ounces (180.) of the salt to 30 gallons of water; 
1 or 2 ounces (30.-60.) of potassium sulphuret may be substituted. 
The water is made demulcent by the addition of starch or of gelatin, 
or by immersing in it a muslin bag containing bran. When it is 
desired to employ the acid bath, \ ounce (15.) of either muriatic or nitric 
acid is added to the quantity of water given above. The bath of this 
size may also be medicated with 1 drachm (4.) of corrosive sublimate; 
or this drug may be used as a lotion in the strength of from \ (0.016) 
to \ (0.033) grain to the pint. Carbolic, benzoic, salicylic, boric, dilute 
hydrocyanic, and dilute nitric acids in weak solution are also employed 
with advantage in some cases. 

Other external applications are thymol, ammonium carbonate, potas- 
sium bromide, ether, chloroform, or chloral-camphor in the strength of 
\ to 1 drachm (2.-4.) to the ounce (30.) of ointment. This ointment 
is prepared by rubbing together equal parts of camphor and chloral 
until a semiliquid results. The preparation is an antipruritic remedy 
of value, but if not largely diluted will increase the uneasy sensations 
produced. In other cases an oily or fatty substance will give more 
prompt relief, especially if the eruption has been irritated by scratching 
and tends to persist. Among useful applications may be named the 
linimentum calcis of the pharmacopeia, and cold-cream salve, to which 
may be added fluid extract of grindelia robusta, 1 part to 20 or 30 of 
vehicle; also the dusting-powders, which are described in the chapters 
relating to General Therapeutics and the Erythemata. These powders 
are the most cleanly of all external preparations in urticaria, and are 
often the only local measures required. Among the Germans sulphur, 
naphtol, and tar-salves are employed in the management of the disease. 

One of the most effective and trustworthy of local applications in 



196 INFLAMMATIONS. 

severe urticaria is a starch solution. The starch is first mixed with 
cold water, and is then boiled until the solution is of the consistency 
of thin mucilage. To each pint of this 1 drachm (4.) of zinc oxide 
and 2 drachms (8.) of glycerin are added before ebullition is completed. 
When cool and applied to the surface this solution often gives prompt 
relief. The same is true of a thin solution of boiled oatmeal. 

Such is the empirical treatment of urticaria. It is founded upon no 
rational method of procedure, because the very capriciousness of the 
disease demands and secures relief in one instance by a treatment 
which should be reversed in another. It must be admitted that cases 
occur in which all treatment seems absolutely valueless, often really 
injurious, to the patient. These cases will usually be found to be of 
the relapsing or chronic type. The subjects of this form of disease are 
often plunged into morbid mental states, dreading by day the exacerba- 
tions of the night, brooding over misfortunes experienced or antici- 
pated, worn by loss of sleep, fearful of a generous regime at the table. 
Here the treatment is largely moral, and demands the tact and courage 
of the physician. Travel, change of climate, variation in the routine 
of life, new social surroundings are here valuable. The widow must 
be made to lay aside the heavy crape-veil beneath which her urticaria 
plays ; the solitary patient must secure an acceptable companion for a 
few hours each day. 

It seems probable that to these efficient agencies must be in part 
ascribed the relief so often obtained at various mineral springs, both 
in America and abroad. Thus, the Karlsbad, Vichy, Saratoga, and 
White Sulphur Springs have all been credited with the production of 
beneficial effects in urticaria. 

Prognosis. — The prognosis of an attack of urticaria is, as may be 
seen in what has preceded, exceedingly variable in different cases. 
Simple attacks of the acute sort are trivial, and in a few days the 
patient may retain but the slightest traces of the trouble. In the case 
of children the attack is often at an end in the course of twenty-four 
hours. 

It should, however, never be forgotten that urticaria may torment 
the life of a patient to the utmost bounds of tolerance and seriously 
impair the general health. Persistent and rebellious chronic urticaria 
may prove to be a more formidable affection than a mild attack of 
syphilis. 

URTICARIA PIGMENTOSA (XANTHELASMOIDEA, Fox). 

Symptoms. — This disorder, once regarded as an affection of great 
rarity, has now been recognized in almost all the large centres of 
population. The disease is characterized by the occurrence in early 
infancy, sometimes but a few hours or a few weeks after birth, of 
elevated, rosy or reddish, round or oval wheals and nodules, which are 
succeeded later by flattish or slightly elevated, light or dark-brownish 
or buff-colored macules. Exceptional cases are reported in which the 
disease made its first appearance a number of years after birth. There 
are three tolerably distinct types of the affection : those exhibiting 



URTICARIA PIGMENTOSA. 



197 



plane lesions with equally flattened maculations ; those with tubercular, 
nodular, or variously sized and shaped wheals ; and mixed varieties, 
the latter being commonest. The mingling of a factitious urticaria 
with lesions long existing and long maculated is not rare. A char- 
acteristic feature of this form of urticaria is the tendency of the wheals 
to recur at the same site, and wmere pigmentation remains new wheals 
may be produced by irritation. Cases may be classified into those 
accompanied by itching and those not thus characterized ; but these 
differences are due to accidental rather than to essential causes. The 
eruption, which at the outset may appear as late as the third year, 
commonly displays itself first on the neck and shoulders, and then 
rapidly spreads to the head and the extremities, eventually invading the 
entire body-surface- — in well-marked cases even including the mucous 
membranes. The lesions are at first 

of the usual urticarial type, each Fig. 41. 

with delicate zone, but soon lose 
their distinct contour and elevation, 
and become flatter and pigmented, 
the color in pronounced cases being 
a distinct yellow, deepening to a 
decided coffee-and-milk hue. After 
isolated tubercles once acquire the 
deeper tint they may persist for 
years ; may return in crops ; may 
even at times be commingled with 
bulla? which desiccate in crusts ; 
may form plaques of infiltration ; 
may be covered with an ery- 
thematous blush due to hyperemia 
of parts long affected ; and, when 
itching is intense, may exhibit the 
general signs of the scratched skin. 
In a few of the reported cases the 
nodules were modified by vesicles 
and vesico-pustules, and were fol- 
lowed by whitish, instead of pig- 
mented, spots in a smooth or 
wrinkled and scar-like skin. 

Etiology. — The cause is un- 
known. The sexes are nearly 
equally represented among patients. 

Pathology. — Sections of tuber- 
cles have been made by numerous 
observers, including Unna, Ray- 
mond, Pick, and Thin. It is clear 
that some effusion occurs in the 

corium with cell-infiltration and small hemorrhages. The disorder 
is unquestionably an angioneurosis due to special changes of the vaso- 
motor centres. Unna has demonstrated that the papillary body in 
these cases is distended by very large flattened mast-cells, the accumu- 




Urticaria pigmentosa. 



198 INFLAMMATIONS. 

lation of which flattens the epidermis above. They lie closely packed 
together arranged in columns by reason of persistence of the collagen- 
ous tissue, between which when spastic oedema is present wide lymph- 
spaces open. 

Diagnosis. — Urticaria pigmentosa is to be distinguished from the 
slight pigmentation left after well-marked urticaria of later years by 
the beginning of the disease in infancy and by the persistent buff- 
colored tubercles. Xanthoma in all its forms is readily distinguished by 
its persistence in special regions, the eyelids, for example.; by its first 
appearance in many patients at a later period of life than infancy ; and 
by its characteristic chamois-leather-yellow shade. 

Treatment. — No treatment has hitherto been so successful as to 
justify its recommendation. The internal remedies and local applica- 
tions advised for urticaria have been employed with varying degrees of 
success. The best results are obtained after stimulating rather than 
soothing baths, at a later period of life than during the first six months. 
After such stimulation with salt and water or alcohol and water a boric- 
acid dusting-powder may be employed. 

ANGIONEUROTIC (EDEMA. 

(Acute Circumscribed CEdema, Acute Idiopathic CEdema, 
Periodic Swelling, Acute Non-inflammatory CEdema, 
Giant Swelling.) 

This disorder described first by Quincke, and since by many other 
observers, 1 is characterized by the occurrence in successive and recur- 
rent attacks, often acute, rarely persistent in character, of circum- 
scribed, cedematous plaques, developing with acute symptoms and as 
rapidly disappearing. The surface of the affected area is commonly 
reddened in various shades, from a light rosy hue to a livid red. The 
plaques vary in size from that of a small coin to that of the section of 
a large orange, and may involve an entire organ or limb. As a rule, 
no itching is awakened. The swellings are commonly the seat of dis- 
agreeable sensations of fulness, burning, throbbing, or scalding ; and 
if the swelling chance to obstruct a mucous tract (nasal, pharyngeal, 
laryngeal, etc.) there are symptoms of a distressing character, due to 
the transitory occlusion. The disease is occasionally noted in connection 
with urticaria, erythema multiforme, and purpura rheumatica. 

Though each individual outbreak may be rapid of occurrence, the 
disorder responsible for the cutaneous symptoms is unquestionably 
chronic in duration ; and it is the successive and repeated expression 
of its influence upon the skin that in rare cases produces a more or less 
persistent and obstinate cutaneous oedema limited to one portion only 
of the integument. 

The lesions occur upon the conjunctiva, the pharynx, the larynx, 
(where even fatal obstructive consequences may result), and also as 
facial symptoms, especially upon the eyelids and the lips. The lesions 
are to be recognized also upon the extremities, the trunk, the penis, 
the scrotum, and the vulva. In some cases the disorder is well nigh 

1 Cf. Courtois-Suffit (Annal. de Derm, et de Syph., 1889, p. 859). 



ANGIONEUROTIC (EDEMA. 199 

universal. When the soles of the feet are involved the erect position 
is impossible without incurring severe pain. The persistent oedema, 
described later and attributed to recurrent attacks of erysipelas and 
lymphangitis, is not of this class. Wende l described a case of acute 
oedema of the dorsum of the hand followed in forty-eight hours by a 
similar lesion on the forearm, and in seventy-two hours by one on 
the face, the attack being accompanied by marked albuminuria and 
haemoglobin uria. 

The cellular tissue of the skin and mucous membranes is chiefly 
involved ; but the papillary portion of the corium is also largely con- 
cerned in the morbid process, as is also the superior vascular plexus of 
the pars papillaris. 

Diagnosis. — The disorder should not be confused with erythema 
multiforme, erythema nodosum, giant urticaria, syphilitic and rheu- 

i matic nodes, nor with pseudo-lipomas. Between these affections, par- 
ticularly between the three first named, no precise lines of demarcation 
can be drawn, and the diagnosis must be made largely from the con- 
comitant symptoms and from the absence, in circumscribed oedema, of 
itching or pricking sensations, febrile complications, and rheumatoid 
pains. 

Treatment. — Circumscribed oedema is produced under the influence 
of the trophic and vasomotor nerves ; it is, hence, amenable chiefly to 

\ those remedial agents which tend to influence favorably the nervous 
centres. Internally ergot, iron, mix vomica, quinine, and the sodic 
salicylate are indicated. As some cases are probably toxic in origin, 
efficient elimination should be secured. Diuretics, sudorifics, and 
cathartics are recommended by Besnier and Doyon. The local treat- 
ment is largely that of urticaria. In chronic cases salt and water may 
be applied over the region of the spine by the hands of a competent 
nurse. The salt is moistened with cold or slightly warmed water, 
according to the constitution and temperament of the patient, and is 
then briskly rubbed with a firm hand over the entire spinal region. 
The back is then sponged for several minutes with pure water, at 
first hot and gradually cooled, until the surface is well reddened, when, 
lastly, the surface is dried and the patient made to take moderate exer- 
cise. The result in cases is brilliantly satisfactory. As in chronic urti- 
caria, mental anxiety and distress, especially in women, may be respon- 
sible for a great part of the trouble. 

Circumscribed and Persistent (Edema of a single member or 
region of the body, not of the class of successive and repeated swellings 
noted above, is properly considered with the early stages of elephan- 
tiasis. It results most often from a localized lymphangitis or so-called 
" recurrent erysipelas " (chronic eczema of the face, tumefaction of 
nose and cheeks due to obstruction by tumors of the antrum of High- 
more), and appears upon the face usually as a smooth, shining, whitish 
or reddish tumefaction, ill defined as a rule, in a few cases with fairly 
good definition. The tuberculous toxins may be responsible for some 
cases. The swelling is usually of firm consistence, but can with some 

1 Jour. Cutan. and Gen.-Urin. Dis., 1899, vol. xvii., p. 178. 



200 INFLAMMATIONS. 

pressure be indented with the finger. It is always the seat of passive 
hyperseinia, never of active inflammation ; but in the case of smokers of 
tobacco and hard drinkers an active inflammation is sometimes awak- 
ened. These patches are rarely painful or tender ; advice is usually 
sought with a view to the relief of the consequent moderate deformity. 
The swellings occur as well upon the lower limbs and breasts of women. 
(Cf. Erysipelas Perstans.) 

The treatment of these cases is by frequent shampooings and em- 
brocations, to stimulate the absorbents, aided by elastic. compression. 
Facial deformities of this class are always benefited by abstention from 
the use of tobacco and alcoholic stimulants, the diet at the same time 
being carefully regulated. The nasal cavity, the region of the orbit, 
and the mouth (caries of the teeth, etc.) should always be examined 
with a view to the removal of the cause. 

DERMATITIS. 

(Ger., Hautentzundtjng ; Fr., Dermatite.) 

Inflammation of the skin occurs in a large number of cutaneous 
affections. Under dermatitis, however, are grouped those inflamma- 
tions only in which the result is plainly due to a direct influence 
exerted upon the skin by thermal, chemical, or mechanical agencies. 
The inflammatory process may involve the superficial or the deep por- 
tion of the integument, or it may extend to the subcutaneous tissues, or 
even deeper. The symptoms vary with the nature of the cause, the 
extent and degree of its influence, and the circumstances attending its 
operation. There may be simple hyperemia and oedema of a few hours' 
duration, or there may follow papules, vesicles, bullae, pustules, and 
crusts. These lesions may be situated on an intensely reddened and 
much swollen base. In severe cases ulceration, gangrene, and exten- 
sive scarring may occur. With these phenomena there may be general 
symptoms of mild or of severe grade, due to the influence exerted by 
the local process upon the general economy. When the exciting cause 
is of moderate intensity but is long continued there results a chronic 
dermatitis in which the skin may be more or less thickened and infil- 
trated, dull red in color, and covered with fine adherent scales. 

DERMATITIS TRAUMATICA. 

External violence, varying in character and severity, is capable of 
inducing dermatitis, the symptoms of which differ in degree, though 
their career is, in general, the same. In this list are included the in- 
flammations produced by surgical interference with the continuity of 
the integument; excoriations caused by scratching, by friction with 
garments and other articles injuriously acting upon the skin ; by the 
various implements handled in the trades ; and by the bites or the 
stings of beasts, insects, reptiles, and fishes, when the result is trau- 
matic and not toxic in character. These injuries may be in the form 
of contusion, blow, concussion, pressure, puncture, incision, or lac- 
aration, and the consequences are declared in heat, swelling, redness, 



</' 



DERMATITIS VENENATA. 201 

and pain ; in itching, burning, stinging, or pricking sensations ; with 
subsequent inflammatory symptoms varying in grade from mild and 
transitory hyperemia and exudation to the severer grades of inflam- 
mation mentioned in the preceding paragraph. 

DERMATITIS VENENATA. 

Certain medicinal and other substances applied to the external sur- 
face of the skin are capable of exciting inflammation by operating either 
as caustic, irritant, toxic, or even traumatic agents. 

Symptoms. — Careful observation of a typical case of dermatitis 
venenata soon after the onset of symptoms will disclose the exact sur- 
face of contact, such surface being delicately outlined by a reddened, 
tolerably well-defined line, within the limitation of which will be seen a 
slightly tumefied, erythematous area, at times displaying closely packed, 
pin-point-sized papules, vesicles, or pustules. As the dermatitis pro- 
gresses it is not necessarily limited to the surface with which the irritant 
has come in contact. The inflammation may extend to adjacent por- 
tions of the skin, or, as a result of absorption and consequent toxic effects 
or of reflex nervous irritation, it may appear on distant surfaces of the 
body. Numerous types of cutaneous lesions — macules, pustules, papules, 
vesicles, bullae, wheals, scales, crusts, free serous and purulent discharges, 
subcutaneous abscesses, and even gangrene with sloughing — may occur, 
the result being largely proportioned to the character of the agent pro- 
ducing the injury and to the susceptibility of the individual. 

Etiology. — Among the sources of dermatitis venenata may be named 
most of the strong acids and alkalies, croton-oil, cantharides, mustard, 
tartar emetic, mezereon, the compounds of mercury, arnica, turpentine, 
ether, chloroform, tarry compounds, resorcin ; many of the dyes, several 
members of the rhus family (Rhus toxicodendron, poison-ivy, and Rhus 
venenata, poison-sumach), the nettle, the smartweed (Polygonum pune- 
tatum), cowhage (Mucuna pruriens), and glass in fine powder or in deli- 
cate filaments, such as are thrust into the skin when handling certain 
articles of Venetian glassware. This list might indefinitely be extended, 
as there are few articles which are not capable of producing some irri- 
tation of the surface of the skin if applied to it with sufficient vigor 
and for a certain period of time ; and in some cases it is difficult to 
decide whether the effect is more traumatic than toxic. An almost 
equally long list of substances of animal origin might be named having 
poisonous effects upon the integument, such as decomposed or am- 
moniacal urine, feces, ichorous pus, and pathologically altered secre- 
tions from the uterus, the eye, ear, nose, etc. 

A few of the more common causes of dermatitis are : the use of 
soap containing an excess of alkali or even minute particles of bone 
for laundry, toilet, or other domestic purposes, as also several of 
the proprietary articles sold in the shops for similar employment. 
Stockings and other undergarments dyed with anilin, picric acid, 
chromium, or arsenic ; the leather lining of the inside of the hat or the 
cap, and the painted toys to which the lips of children are applied, will 
beget mischief in the various regions of contact for each. Duhring 



202 INFLAMMATIONS. 

reports cases in which the dyestuff in the lining of shoes penetrated the 
material of stockings in women, and produced dermatitis of the feet 
or the legs. 

The tincture of arnica, an article much used as a domestic applica- 
tion for contused and incised wounds of a simple character, has pro- 
duced very serious annoyance in some cases, two such having been 
recently presented at the authors' clinic. The number of these acci- 
dents is annually increasing. Cartier l reports excessive erysipelatous 
swelling, a phlyctenular eruption, and submaxillary adenopathy result- 
ing from the external use of arnica. Beauvais reported to the Paris 
Medical Society gangrenous results in one case. Buchner believes this 
poisonous action to be due to insects (particularly the Atherix maculatus) 
found in the calyx of the arnica-flower. Other native plants, a large 
number of which are enumerated in a valuable monograph by White, 2 
presented in 1886 before the American Dermatological Association, are 
similarly effective. Wesener 3 reports that the Malacca bean-tree (An- 
acardium orientale) furnishes a caustic oil, called " cardol," or " car- 
doleum pruriens," that produces, after application to the skin, vesicles 
and vesico-pustules which contain cardol and terminate by crusting. 
He reports a generalized eruption, beginning on the face, due to this 
cause. 

The antiseptic dressings of modern surgery are at times responsible 
for eruptive troubles. Among these antiseptics may be named iodo- 
form, which has produced erythema, vesicles, pustules, and wheals. 4 
Carbolic-acid and corrosive-sublimate dressings have had similar effects. 
Many of the articles employed therapeutically by the dermatologist 
should be placed in the same category. Green, 5 of London, reports 
oedema of the skin followed by desquamation, resulting from the appli- 
cation to it of the ointment of ammoniated mercury in the strength of 
2 drachms (8.) to the ounce (32.). 

Leszinsky reports a case of dermatitis of the face following the use 
of a " triple extract of heliotrope " as a toilet-preparation. 

An exceedingly common source of dermatitis is urine retained upon 
underclothing of adults. A persistent dermatitis of the scrotum, the 
perineum, or the inner faces of the thighs in either sex, always calls 
for examination as to whether a few drops of urine are not left in con- 
tact with such underclothing after each act of micturition. Fistula?, 
urinary incontinence, prostatic disease, " stammering of the bladder," 
imperfect finish of the coup de piston in men, especially after a gonor- 
rhoea and similar troubles, are all to be remembered. 

The eruption produced by the Poison-ivy and other varieties of 
rhus is almost exclusively an American disease ; and from its frequency 
in the United States has attracted a great deal of attention. A certain 
degree of susceptibility to the poisonous action of the plant is requisite 
for the production of its effects, as some individuals can handle the 
leaves of the plant with impunity, while others, it is claimed, are 

x Lyon Med., April 13, 1884. 

2 Dermatitis Venenata. Boston, 1887. 

3 Deutsche Arch. f. klin. Med., vol. xxxvi., p. 578. 

4 See paper of K. W. Taylor, read before the New York Academy of Medicine, 1887. 

5 Brit. Med. Jour., May 3, 1884. 



DERMATITIS VENENATA. 203 

affected by its exhalations within a circle having a radius of several 
feet. It is, however, difficult to demonstrate the truth of the last state- 
ment, suspecting, as one may, that such instances may be cases of con- 
tact with other than the suspected plant. The parts commonly affected 
are the hands and the regions to which the latter are carried, such as 
the face, the genitals, the arms, the thighs, and the neck ; barefoot 
children suffer in the feet and the legs. Usually the symptoms are 
developed in the course of a few hours, and they consist of eryth- 
ematous patches; scanty or profuse vesiculation with abundant serous 
weeping after rupture of the lesions ; swelling, oedema, and disfigure- 
ment ; and intense burning and itching sensations. Serious effects are 
occasionally produced. Deeply attached scars may result from subcu- 
taneous abscesses of parts greatly swollen. Occasionally in particu- 
larly sensitive skins the eruption spreads from the skin-surface affected 
by the poison to that where presumably none has been applied. It 
should be remembered, however, that articles of clothing may for brief 
periods of time furnish sources of further trouble, being worn at the 
moment of contact witli the plant, then laid aside, and, the occasion 
quite forgotten, being subsequently employed. Thus, a pair of un- 
dressed-kid gloves after lying for two weeks untouched have sufficed 
to awaken the disease. 

A number of cases of dermatitis have originated in some parts of 
the Orient from contact with the varnish employed in the finishing of 
lacquered ware. This lacquer is manufactured from a rhus varnish. 
A few instances of such dermatitis have occurred in America from 
handling newly imported articles of this class. 

Diagnosis. — An acute dermatitis appearing suddenly on regions of 
the body readily exposed to toxic agents should always arouse sus- 
picion of dermatitis venenata. A history of contact with some irritat- 
ing substance can usually be obtained. The intlammation in the begin- 
ning is limited to the areas with which the toxic agent came in contact, 
is often asymmetrical, and has no relation to the general health of the 
patient. The process often reaches the point of greatest intensity 
within a day or two after its first manifestations, and subsides soon 

1 after removal of the cause. 

The peculiar features of ivy-poisoning have been described in a 
monograph on the subject by White, of Boston. 1 According to this 

( author, the lateral surfaces of the digits first exhibit the symptoms of 
the eruption, later the dorsal surfaces, and latest the thickened palms. 
The efflorescence also is more irregularly distributed, more uniformly 
vesicular, and the vesicles are less transparent than in eczema. The 
lesions, moreover, are more vesicular and less papular at the outset, 
and, though suggesting papules by their situation in the palm, are in 
that situation readily made to exude serum by puncture with a needle. 
Treatment. — Internal medication is not required. The local treat- 
ment is that of acute eczema. Black wash (preferably dilute), solution 
of sugar of lead, or oleated lime-water may be employed at first, and be 
followed later by dusting-powders. 

1 New York: D. Appleton & Co., 1878, from the March number of N. Y. Med. 
Jour, of the same vear. 



204 INFLAMMATIONS. 

In ivy-poisoning the application of an alkali, for the purpose of 
neutralizing the poisonous volatile alkaloid in the leaves of the plant 
(toxicodendric acid, Maisch), should evidently be considered solely with 
a view to prophylaxis, as it is difficult to understand how such neu- 
tralization can control the inflammatory process after its onset. The 
late Prof. Babcock, of Chicago, a frequent sufferer from this disease 
following his extended botanical excursions, first made known the value 
of an ointment made by incorporating a decoction of the inner bark of 
the American spice-bush (Benzoin odoriferum) with colcl-cream salve. 
It affords prompt relief in cases in which it is employed, the difficulty 
lying in securing the bark of the shrub in its young and tender 
state. 

Many topical remedies have been vaunted as specifics for the relief 
of this disorder, from the brine of a pork-barrel to a decoction of the 
leaves of the plant itself. As the eruption usually subsides when the 
skin is protected and not irritated by the local treatment, it is not dif- 
ficult to explain the result in most eases, though it is possible there is a 
parasitic element in the poison. Corrosive-sublimate lotions; saturated 
solution of boric acid ; Carron oil ; 50 per cent, solution of ichthyol ; 
tincture of iron; bromine, 15 drops (1.) to the ounce (30.) of olive-oil 
(Brown) ; dilute nitric acid ; sodium hyposulphite ; sodium bicarbonate ; 
saturated solution of potassium chlorate; and grindelia robusta, 1 
drachm (4.) of the fluid extract to 8 ounces (250.) of water, have each 
been found useful. Complete covering of the affected area with flexible 
collodion is frequently effective. 

DERMATITIS CALORICA. 

Under this title are included those affections of the skin induced by 
extremes of thermal variation. 

Unduly high temperatures produce in the skin redness in varying 
shades and a slight degree of swelling, the color not completely disap- 
pearing under pressure. If the exciting agent be withdrawn before 
further effects are induced, the color first deepens, then becomes paler, 
and in twenty-four hours the process is usually concluded with a very 
delicate and transitory resulting pigmentation. 

Rays of heat and heated objects at a temperature from 125° to 
175° F. produce immediately, or after a brief interval, first, an erythema, 
which disappears when the source of the heat is removed; second, 
after more prolonged exposure, the symptoms of active inflammation 
and exudation. Vesicles or bullae, isolated or confluent according 
to the severity of the cause, may rise from a reddened skin which 
is usually intensely painful. These lesions are persistent or are 
transitory, and are generally filled with a clear serum, which exudes 
and dries into crusts after rupture of the chamber in which it was 
imprisoned. At other times the exudation is so abundant that the 
epidermis rises in broad plates, from beneath which the serum is ex- 
uded. This process may terminate by a free production of pus upon 
the surface and gradual resolution. Adenopathy is a frequent concom- 
itant symptom. In such dermatitis of extensive areas of the skin the 



DERMATITIS CALORIC A. 205 

intensity of the process may awaken a violent fever, or death may 
result from shock or exhaustion. 

In yet severer grades there is the production of an eschar, which is 
dry, brown, blackish, and destitute of all signs of vitality ; or, as 
Kaposi describes it, is dense, coriaceous, and white as alabaster, 
though upon the eschar some vesicles appear, and by their presence 
suggest a false conclusion as to the vitality of the tissues upon which 
they rest. In from eight to ten days the slough is removed by sup- 
purative processes, and the scene is closed by the usual phenomena of 
granulation and cicatrization. The characteristics of the scar thus 
produced are : its great irregularity, its tendency to stellate radiation, 
and the production of ridges, folds, pockets, and bridles. 

Burns involving one-third the body-surface are of grave portent, 

and those affecting one-half the body are generally fatal, even though 

for from twenty-four to forty-eight hours there may be little complaint 

of pain. The causes of death in these fatal cases are generally obscure, 

as the post-mortem results are usually negative. Gastric and duodenal 

ulceration, however, is often recognized. Overheating of the blood, 

heart-paralysis, oligocythemia, and actual destruction of leucocytes 

have all been supposed to be effective in bringing about dissolution. 

j In cases in which life is prolonged to the third day the complications of 

i pyaemia, erysipelas, and tetanus may arise. Lastly, exhaustion fol- 

; lowing fever, suppuration, hemorrhage, and visceral affections may 

lead to fatal results. 

Treatment. — In the treatment of the simplest burns, rest, lotions of 
, lead-water, and cool water, with the application of compresses, are 
| usually sufficient to secure relief; occasionally, dusting-powders may 
advantageously be substituted. In the cases in which serum is brought 
1 rapidly to the surface, with the production of vesicles and bullae, the 
latter should be punctured skilfully to give relief to the tension by the 
evacuation of their contents, but the roof-wall should be preserved, as 
it may subsequently form an attachment to the exposed derma be- 
neath. The indications then are to exclude the air as perfectly as 
possible and to prevent suppuration, indications which are admirably 
met by the application of carbolated oil and lime-water with the Lister 
dressing. Continuous immersion in water having the temperature most 
agreeable to the patient, as practised by Hebra in cases of severe and 
extensive burning, produces a speedy and certain amelioration of the 
pain and a favorable condition of the wounds, though it does not avert 
a fatal issue in any dangerous case. 

The strictest antiseptic precautions are demanded when the suppura- 
tive process in the skin is both active and extensive. Disinfection 
with a 5 per cent, solution of carbolic acid, or a 2 per cent, resorcin 
solution, should be followed by the application of protective silk wet 
with a 5 per cent, solution of sodic biborate or bicarbonate, and the 
whole enveloped either in borax-lint, antiseptic (mercuric iodide) wool, 
carbolized gauze, or salicylated cotton ; over all, impermeable rubber 
tissue should be wrapped. 

Mtzsche l first disinfects the burnt surface thoroughly with carbolic 

1 Deutsche med. Zeit, 1881. 



206 INFLAMMATIONS. 

acid, having previously protected the blebs, after which it is covered 
with a thick varnish of linseed-oil and litharge mixed by the aid of 
heat with 5 per cent, of salicylic acid. When this coat is dry a sec- 
ond coat is applied, and the whole is finally covered with a thick 
layer of wadding retained in place by an elastic bandage exercising 
moderate compression. Cicatrization progresses beneath the dress- 
ing without changing the latter. When suppuration occurs the 
upper layer of wadding is removed, and dried salicylic acid in 
powder is sprinkled over the surface, the wadding being afterward 
reapplied. 

Skin-grafting may be required to cover the extensive ulcers left by 
the larger burns. 

Congelatio, or dermatitis from congelation, presents usually in 
the milder forms circumscribed erythematous patches or plaques, gen- 
erally recognized under the name of Pernio, or chilblain, seated upon 
the digits or, more rarely, upon the face, and occasioning a disagree- 
able sensation of heat, smarting, or itching, especially after the chilled 
part has been warmed. 1 Chilblains are bluish or purplish red in 
color, and are often seated on a slightly oedematous integument. They 
are generally cool to the touch when subjectively hot. Authors have 
claimed that anaemia is a chief predisposing cause of the complaint, but 
it frequently occurs in perfectly healthy young people. Sir Erasmus 
Wilson has suggested that some cases of so-called "lupus erythema- 
tosus " of the hands belong to this category. 

In the second grade of inflammatory reaction, following the state of 
contracted blood-vessels and pallid integument produced immediately 
by the action of cold, bullae and vesicles form, with underlying ulcers 
in severe cases. 

In the third grade gangrene may occur, with and without the forma- 
tion of bullae. The frozen part may become insensitive, white, and 
cold, without the circulation in it of blood- and lymph-currents. From 
this condition reaction occurs, with the formation of an eschar, differing 
after the death of the patient according to the severity of exposure to 
cold. If, however, beside the interference with the circulation, the tissue 
itself has been destroyed, when reaction occurs the part falls at once 
into gangrene ; or there form bullae larger than those described above, 
filled with sanguinolent serum ; or the skin is smooth, marbled with 
bluish lines, whitish, cold, and insensitive. Mortification ensues, 
followed by the well-known phenomena of the " line of demarcation," 
and, in favorable issues, suppurative separation of the dead part, gran- 
ulation, repair, and cicatrization. As the injuries induced by conge- 
lation are more frequent upon the extremities, the bones, especially 
those of the digits, largely participate in the losses of tissue. Septi- 
caemia and a fatal result may follow. 

Chilblains are treated internally by the ferruginous tonics, particu- 
larly the tincture of iron, externally by stimulant applications, such 
as those containing iodine, camphor, carbolic acid, tincture of benzoin, 
and balsam of Peru. Kaposi recommends : 

1 Consult the chapter devoted to the Erythemata. 



DERMATITIS MEDICAMENTOSA. 207 

R Pulv. camphorae, gr. x; 66 

Cretse prseparat., Jj ; 30 

01. lini, f gij; 60 

Balsam. Peruvian., wixx; 1J33 M. 

Frictions, with or without medication, are generally useful. The 
parts are to be carefully protected from pressure and undue friction- 
effects. 

Dilute nitric acid and peppermint- water in equal proportions, 
painted over the part for three or four successive days, have been 
recommended by Lapatin for the treatment of frost-bitten fingers and 
toes. Hydrochloric and pyroligneous acids, lemon-juice, 50 per cent, 
and stronger solutions of ichthyol, collodion, and lead acetate, both in 
lotions and poultices, are also recommended. Meurisse advises in the 
i management of both severe ambustio and congelatio that goldbeaters' skin 
be employed over any salves or lotions applied to the affected surface. 
In cases of severe congelation the circulation is to be cautiously 
• restored by friction performed in an apartment the air of which is 
; cool, to prevent too energetic reaction. Friction with snow is em- 
ployed with safety in America and on the steppes of Russia, where 
these accidents are frequent and are grave in results. Perseverance 
i for hours in this course is often rewarded with success in apparently 
i desperate cases. Antiseptic dressings are usually demanded when 
i sloughing and ulceration ensue. 

DERMATITIS MEDICAMENTOSA. 

The importance of recognizing the fact that a given eruption is 
produced by an ingested drug can scarcely be overestimated from the 
point of view of the diagnostician. The errors committed in this con- 
nection are so frequent and so annoying to the patient that it is neces- 
i sary for the physician to inquire very carefully, before treating any 
i cutaneous disease, as to the medicaments previously swallowed by the 
patient, and also to be prompt to connect any aggravation of a cutane- 
ous disease with remedies ordered by himself for internal use. The 
J following is but an imperfect list of the drugs the internal adminis- 
J tration of which may be followed by an exanthem — imperfect, because 
without question many have yet to be recognized as possessing such an 
1 action. As to the modus operandi of such medicinal agents, for the 
I most part our knowledge on this subject is purely conjectural. Some, 
for example potassium iodide, are eliminated in part by the glands of 
the skin, and presumably have thus a local effect upon such emunc- 
' tories ; others, and in this class, probably, should be included quinine, 
induce an urticaria scarcely to be distinguished from an urticaria ab 
ingestis. Some operate, possibly, in either or both ways at different 
times or in different individuals. The absurdity of supposing that 
any disease can be " driven out " by the ingestion of such drugs should 
be relegated to the specious ignorance which first framed such an 
hypothesis. 1 

1 For full details of this subject, consult the treatise on Drug-eruptions, by Prince 
A. Morrow. New York, 1887. 



208 IN FLA MM A TIONS. 

Acids. — The acids capable of producing macules, papules, erythema, 
desquamation, etc., are carbolic, nitric, tannic, benzoic (and sodium ben- 
zoate), and boric (and sodium borate). 

Modadewkow reports a case in which the pleura was washed out with 
a 5 per cent, solution of boric acid, a part of which was not removed. 
There occurred as a result an erythematous rash over the face, the 
trunk, and the extremities. 

Aconite. — This drug is said to be productive at certain times of 
marked diaphoresis with the occurrence of vesiculation and consider- 
able itching. The diaphoresis in an irritable skin may be responsible 
for the trouble. 

Antipyrin and Other Kemedies of its Class (manufactured by the 
action of glacial acetic acid upon the petroleum-products). — Ernst 1 has 
been followed by many observers in recording rashes resulting from 
the administration of antipyrin. The symptoms are discrete and con- 
fluent patches of bright-red, scarlatiniform, erythematous, and pru- 
ritic macules or papules. Veiel 2 reports oedema with bullae upon the 
lips and toes, and over the palate, with urticarial lesions of the palms 
and soles, after ingestion of antipyrin. Brocq, Darier, and others have 
reported cases in which antipyrin has produced a more or less persist- 
ent erythema in the form of isolated, scattered, sharply defined plaques. 
These plaques are usually few in number, and they tend to return in 
the same sites whenever the susceptible individual ingests the drug. 
The redness and pigmentation may persist for several weeks. Wick- 
ham reports an antipyrin-rash which simulated perfectly a macular 
syphiloderm. 

Arsenic. — Erythematous, vesicular, papular, and much more rarely 
pustular, bullous, and ulcerative lesions occur upon the face, the 
back, and the hands after the ingestion of arsenic. The well-known 
effects of the administration of the drug in toxic doses upon the 
mucous membranes of the eyes, nose, and mouth need not be 
described in this connection, nor yet the grave gangrenous symptoms, 
with osseous necrosis, that have been observed in workers in the 
metal. 

A bright-red, scarlatiniform blush with a few isolated vesicles has 
covered both shoulders of a young Avoman with a delicate skin after 
taking three medicinal doses of Fowler's solution, the eruption being 
present but less distinct upon her face and hands. In two cases the 
rash in polymorphic type was limited to the hands alone. 

Youug patients who have taken arsenic in the largest medicinal 
doses for relief of chorea often present as a result a dark discoloration 
chiefly of the skin of the chest and the neck, but also of other parts of 
the body. This discoloration is suggestive of the bronzing seen in 
Addison's disease. In some instances there are no other cutaneous 
symptoms. Guaita and Liege noted these phenomena usually in the 
fifth month after ingestion of the drug. 

Long-continued use of arsenic may produce keratosis of the palms 
and soles of a severe grade, obstinate character, and occasionally grave 



1 Centralb. f. klin. Med., 1885. 

2 Arch. f. Derm. u. Syph., 1891, Hft. 1. 






DERMATITIS MEDICAMENTOSA. 209 

results. Administered for relief of psoriasis, the resulting keratoses 
have later developed into epitheliomata of malignant type. 

By far the largest number of rashes are, however, produced in per- 
sons previously suifering from the cutaneous disease for the relief of 
which the drug is administered. Here the toxic effect is declared by 
either — first, increased hyperemia of the skin, visible in an erythema- 
tous patch, or beneath the scales of a squamous patch, or as an areola 
of bright-red hue about any aggregation of lesions ; second, by simple 
aggravation of the type of a disease already in existence (recurrence 
of acuity in a subacute eczema) ; third, by rapid peripheral extension 
of a disease which had previously been well limited in contour ; fourth, 
by converting a disease exhibiting uniformity of lesions into one char- 
acterized by multiformity. Each of these results might be illustrated 
by cases. 

In a series of eight cases of poisonous effects produced by arsenical 
paper-hangings, and reported by Brown, 1 there were, curiously, no 
cutaneous symptoms. 

Belladonna. — The well-known erythematous, scarlatiniform, or red- 
dish efflorescence produced by belladonna and its alkaloids is usually 
limited to the upper segment of the body, but it may become general- 
ized. It is said to occur more frequently in children, probably because 
it has been administered largely to individuals of that age under the 
delusion that it is useful as a prophylactic in scarlatina. Very dis- 
agreeable and even dangerous results have followed the instillation into 
the eye of atropine as a mydriatic, the rash being accompanied by con- 
stitutional symptoms. 

Bromine and its Compounds. — A full account of the cutaneous 
effects of bromine and its compounds, when administered internally, 
is contained in a paper on medicinal eruptions, read in 1880, by 
Van Harlingen, of Philadelphia, before the American Dermatological 
Association. Acneiform lesions, pustules, macules, maculo-papules, 
papules, eczemaform moist patches, furuncles, urticarial wheals, scales, 
and ulcers have been induced by swallowing the bromides of potassium, 
sodium, ammonium, and lithium. By far the commonest are the 
acneiform and pustular lesions, occasionally accompanied by pruritus, 
which appear upon the face and the upper portion of the trunk, 
though the rash may be very distinct upon the genital region. Duhring 
reports an interesting observation of a patient in whom the eruption 
simulated closely the maculo-papular syphiloderm, the patient having 
taken a bromine salt for three years. The eruption first appeared 
within five or six days after decreasing the dose. Kaposi observed 
a case of bromide-rash in a nine-months-old suckling, the mother 
having taken 120 grammes of potassium bromide in two months, 
herself exhibiting no traces of eruption. 

A remarkably characteristic exanthem is produced by the admin- 
istration of potassium bromide, especially to infants and young chil- 
dren. The lesions are condylomaform, quite numerous, conspicuous 
about the face and neck, where they are packed closely together, but 
they are also seen on other parts of the body. The small coin- to nut- 

1 Paper read before the Boston Society for Medical Observation, March 6, 1876. 
14 



210 I NFL A MM A TIONS. 

sized elevated nodules are usually flattened ; and they often resemble 
carbuncles, as they have a cribriform summit on which multiple points 
of imprisoned pus are visible. This rash, though rare, has been care- 
fully studied and well illustrated by chromo-lithographic reproductions. 

T. C. Fox and Gibbes report these condylomaform nodules in the 
case of an infant in which the histology of the lesions was carefully 
studied ; and Fay in a child eleven months old also recognized an 
exanthem which had been mistaken for molluscum epitheliale. These 
lesions are somewhat similar to the condylomaform rash seen in chil- 
dren after the administration of potassium iodide. 

Browse, of Cambridge, England, recommends for relief of these 
symptoms the application of a solution of salicylic acid, 1 grain to the 
ounce (0.066-30.) of water, frequently applied on lint, he having suc- 
cessfully treated in this way sores as large as the palm of the hand. 

Cannabis Indica. — The only instance reported of an eruption pro- 
duced by the ingestion of this drug was observed by one of us in the 
case of an adult male, who was extensively covered with papulo-vesicular 
lesions after swallowing 1 grain (0.066) of the extract. 1 

Chloral. — An erythematous rash is the commonest of the eruptions 
produced by chloral, though wheals, red and yellowish papules, vesi- 
cles, pustules, and petechial blotches have been observed. The rash 
occurs upon the face, the neck, the trunk, and the limbs, of the latter 
especially on the extensor surfaces. In a man of advanced years 
and totally deaf, who had slept only under the influence of chloral for 
four years, discrete scaly patches as large as saucers covered the hands 
and the lower extremities. 

Martinet 2 reports an erythematous and scarlatiniform rash, occa- 
sionally commingled with urticarial and purpuric lesions, occurring 
upon the face and neck, the front of the chest, the extensor surfaces of 
the larger joints, and the dorsum of the hands and feet. There was 
no pyrexia nor indisposition, but in some cases there were dyspnoea 
and cardiac palpitation. 

Cod-liver Oil. — According to Farquharson, 3 cod-liver oil after 
being swallowed is capable of producing an acne. This result is trace- 
able to the use of inferior qualities of the oil. 

Copaiba and Cubebs. — The ingestion of copaiba is occasionally fol- 
lowed by a vividly red rash, in the form of discrete macules, more 
rarely maculo-papules, invading chiefly the lower segments of the 
extremities and the skin of the belly, but often completely covering the 
body-surface. The rash may occur in dark mulberry-red petechia, and 
is always accompanied by pruritus. Inasmuch as the drug is often 
administered for the relief of a venereal disorder not syphilitic, care 
should be taken not to confound the eruption it may excite with the 
early macular syphiloderm. Cubebs is much more rarely followed by 
a similar result. 

Condurango. — Guntz 4 reports the occurrence of furuncular and acnei- 

1 N. Y. Med. Record, May 11, 1878. 

2 These de Paris, 1879. 

3 Brit. Med. Jour., Feb. 22, 1879. 

4 Vierteljahrschft. f. Derm. u. Syph., 1882. 






DERMATITIS MEDICAMENTOSA. 211 

form lesions in twenty patients out of one thousand who were taking 
condurango for the relief of syphilis. 

Digitalis. — In Behrend's treatise on diseases of the skin l reference is 
made to cases in which macular and maculo-papular rashes succeeded 
the ingestion of digitalis. 

Iodine and its Compounds. — Potassium iodide is responsible for the 
larger number of all eruptions among medicinal rashes. The frequent 
employment of this drug and the very marked influence it possesses 
over the skin render the study of these morbid results important. 

Fig. 42. 




Papilloma, due to the ingestion of the iodine compounds. 

Unlike many of the other substances in the list of drugs, the iodine 
compounds are followed by some species of rash in probably the larger 
number of all persons who swallow them. As is true also with the 
bromine compounds, the eruption may persist, or even first appear, 
after the drug has been discontinued. 

The resulting lesions may be macular, papular, vesicular, bullous, 
pustular, petechial, multiform, or may be circumscribed subcutaneous 

1 Braunschweig, 1879. 



212 INFLAMMATIONS. 

abscesses. In appearance the rashes produced by iodine and its com- 
pounds may simulate those of every other dermatitis. 

The macular rash is best seen fully developed over the upper 
extremities in discrete erythematous patches or as a diffuse blush. 
Generally the rash is displayed symmetrically. The hands are often 
affected, and suggest in appearance the hands of the anilin-worker. 
The rash assumes at times the papular type with special production of 
papules upon the face. 

Berenguier describes a scarlatiniform rash of sudden occurrence, 
with numerous minute discrete vesicles upon the surface of the skin. 
Eczemaform eruptions with abundant serous exudation are also reported. 

A number of cases are on record in which the administration 
of the drug was followed by the production of bullae. Bumstead, 
Taylor, Duhring, Tilbury Fox, Finny, and one of us have described 
such bullae in adults as well as in children. 1 Hallopeau 2 also reports 
a fatal case in which a bullous eruption followed the ingestion of 
potassium iodide. The eruption occurred chiefly about the head and 
neck and the upper extremities. The significant rarity of vesicu- 
lar and bullous lesions in acquired syphilis suggests that at least some 
of the cases on record were those of rashes induced by the remedy 
given for the relief of the disease. 

A careful analysis of these bullous rashes leads to their division into 
three categories : first, those occurring, often with fatal results, in 
cachectic adult patients ; second, those occurring as part of the eruptive 
lesions in a polymorphic group ; third, those occurring in well-nour- 
ished children, and taking on the appearance of molluscum epitheliale 
and condyloma-lesions, usually compounded of papulo-vesicles and 
pustules. Erythanthemata of a similar type have also been recognized 
after the ingestion of potassium bromide by infants. 

The pustules induced by the administration of iodine compounds are 
seen chiefly upon the face, the neck, the trunk, and the arms. They 
are usually seated upon a firm base, and may be followed by cicatrices. 
Duhring has seen an annular patch upon the forehead, made up of 
minute vesico-pustules, which eventually developed into a globular 
violaceous mass nearly two inches in diameter. Large, cherry-sized, 
tubercular or papillomatous elevations abruptly rising from the surface 
of the integument may present a cribriform structure, which shows the 
open ducts of several suppurating follicles (chin, cheek, nose). A few 
cases are reported in which fungating tumors were found, producing 
an appearance almost identical with that of mycosis fungoi'des. Neu- 
mann 3 calls attention to the fact that these severe forms of iodide- 
eruption occur in patients suffering from albuminuria. 

The purpuric rash occurs in petechial macules, discrete and miliary, 
situated chiefly on the lower extremities. In a case reported by Mac- 
kenzie (quoted by Van Harlingen) a dose of 1\ grains (0.166) taken 
by an infant was followed by a fatal result after petechia? appeared. 

Jaborandi and Pilocarpine are capable, when ingested, of inducing 

1 Arch, of Derm., October, 1870. Jour. Cutan. and Ven. Dis., 1886, p. 383. 

2 Union Med., March 25, 1882. 

3 Arch, f, Derm. u. Syph., 1899, vol. xlviii., No. 3. 






DERMATITIS MEDICAMENTOSA. 213 

free diaphoresis ; erythematous macules, wheals, and pinhead-sized 
papules have been seen upon the surface as a result. 

Mercury. — Mercury when ingested is reported to have produced an 
erythematous rash upon the surface of the skin. In view of the fact 
that the metal has been, in its various compounds, administered for so 
long a period of time and for so many various diseases, without the 
production of cutaneous symptoms, it is a fair hypothesis that in the 
few reported cases there was coincidence rather than causation. Mer- 
curials when applied to the external surface of the body are, as is well 
known, capable of exciting, in various degrees, cutaneous irritation and 
inflammation. 

Opium and its Alkaloids. — -Erythema, wheals, and occasionally in- 
tense pruritus, with oedema, and subsequent desquamation, have fol- 
lowed the ingestion of opium and several of its alkaloids, notably 
morphine. In its mildest expression this cutaneous effect is limited to 
a characteristic itching about the nostrils that can be perceived in a 
large proportion of all patients as soon as the general effect of the 
opiate becomes apparent. In some patients there may follow an in- 
tense* and distressing general pruritus without efflorescence, and it is 
certain that the subsequent urticarial efflorescence is caused by the free 
diaphoresis which the medicament induces. This fact is a matter 
of practical moment, as the use of an anodyne for the purpose of 
procuring sleep for a patient tormented with a nocturnal pruritus 
would seem to be occasionally indicated. Inasmuch as chloral, potas- 
sium bromide, and the opiates are all capable of aggravating such dis- 
tress, great caution is needful in such emergencies. In general, it may 
be said that the employment of these and similar remedies for the relief 
of pruritus should be interpreted as a confession of weakness on the 
part of the physician, who ought to be able to alleviate the distress of 
his patient by a judicious employment of topical remedies. 

Petroleum and its products are responsible for a large list of medic- 
mentous rashes (see Antipyrin, etc.). 

Phosphorus.— Hasse (quoted by Van Harlingen) cites the case of a 
young girl who exhibited a pemphigoid rash after the ingestion of 
phosphoric acid. According to Farquharson, 1 phosphorus itself is oc- 
casionally responsible for purpura with gastro-intestinal derangement 
and jaundice preceding a fatal issue. 

Podophyllin. — Winterburn 2 reports that those who work in resinoid 
podophyllin are liable to suffer, as a consequence of this exposure, from 
a cutaneous disease of the scrotum. 

Potassium Chlorate. — Stelwagon and others report that papules and 
macules have followed the use of this remedy, administered in the form 
of tablets. 

Quinine, Cinchona, and Cinchona Alkaloids. — Morrow 3 collected the 
records of over sixty cases of quinine-exanthem, and he shows that 
its prevailing type is exanthematous, the rash being of a vivid 
hue, disappearing on pressure, and resembling scarlatina. Other 

1 Loc. cit. 

2 Louisville Med. News, April 21, 1882. 

3 N. Y. Med. Jour., March, 1880, p. 244. 



214 INFLAMMATIONS. 

lesions produced are wheals, papules, vesicles, petechia, hemorrhagic 
purpura, bullae, and in one instance an intense localized dermatitis 
with beginning gangrene of the scrotum. In some of the cases the 
rash appears on repetition of the dose, and even after recourse to 
other alkaloids. The subjects are mostly women. As with most of 
the other exanthem-producing drugs, small doses suffice for the effect 
where the idiosyncrasy exists. The rash has been studied in an adult 
male, who, after taking 2 grains (0.133) of quinine sulphate for the 
first time in six years, exhibited an efflorescence (over the entire sur- 
face of the body) of discrete, finger-nail-sized, salmon- and pinkish- 
tinted, scarcely elevated patches, accompanied by moderate pruritus. 
A repetition of the dose was followed by a recurrence of the 
exanthem. 

In several cases desquamation is reported as resulting from the rash. 
As to the occurrence of the general symptoms recognized under the 
title " cinchonism " (tinnitus aurium, etc.), these may and may not 
accompany the lesions. Morrow makes the pertinent suggestion, in 
view of the frequent similarity of the rash to that exhibited in scarla- 
tina, that many cases hitherto recorded as recurrent attacks of that 
disease and measles, with other anomalous cutaneous eruptions, may 
have been instances of quinine-exanthem. 

Salicylic Acid and the Salicylates. — Reports of cases in which these 
substances after ingestion produced cutaneous symptoms have been 
made by Heinlein, Wheeler, and Freudenberg, all cited by Van Har- 
lingen. The symptoms were diffused redness, urticarial lesions, vesi- 
cles, pustules, petechia?, and vibices, accompanied by intense pruritus 
and followed by desquamation. Engman 1 reports an interesting case, 
including the histology of the lesions. 

Salipyrin. — (Edema of the skin and actual loss of tissue have resulted 
from the administration of gramme doses of salipyrin to a man aged 
fifty-four years (Schmey). 

Santonin. — A generalized eruption of urticarial lesions seated upon 
a reddened surface and accompanied by oedema is reported by Sieve- 
king as occurring in a child to whom santonin had been administered 
as a vermifuge. 2 

Sodium Benzoate. — Roh6 3 reports two cases in which an erythema- 
tous rash, with well-defined border, accompanied by itching and slight 
desquamation, occurred during the use of sodium benzoate. The patients 
were a woman, aged thirty-five years, and a boy suffering from diph- 
theria. The eruption disappeared on discontinuance of the remedy, 
and was made successively to appear and disappear by its alternate use 
and disuse. 

Sodium Biborate. — Gowers 4 reports the occurrence, especially on the 
arms, but also over the trunk and legs, of an eruption resembling 
psoriasis, after the ingestion of sodium biborate. Some of the 
resulting patches were one and a half inches in diameter. Three cases 

1 Jour. Cutan. and Gen.-Urin. Dis., 1899, p. 555. 

2 Brit. Med. Jour., February 18, 1871. 

3 Maryland Med. Jour., June 15 1881, p. 91. 

4 Lancet, September 24, 1881. 






DERMATITIS MEDICAMENTOSA. 215 

in all are collated. In two the eruption faded when a solution of 
arsenic was added to the sodium salt. 

Stramonium. — Deschamps (cited by Duhring) reports an erythema- 
tous rash after the administration of the thorn-apple. 

Strychnine. — Skinner (cited by Van Harlingen) reports a case in 
which an eruption of six weeks' duration ensued upon the administra- 
tion of quinine and strychnine together ; the former in the dose of 1^ 
grains (0.10), the latter in the dose of -^ grain (0.0025). 

Tanacetum. — A case of varioliform eruption produced by the inges- 
tion of 1^ drachms (6.) of the oil of tansy, administered for abortifa- 
cient purposes, is reported by Potter. 1 There were antecedent clonic 
convulsions. The result was not fatal. 

Tar and Turpentine. — Erythematous, vesicular, and papular rashes 
are reported as resulting from the ingestion of these substances. 

The following medicaments may be added to the list of drugs 
capable of producing rashes when administered by the mouth : 

Anacardium, alcohol, bitter almonds, antimony, argenti nitras, benzol, 
chinolin, bitter-sweet, capsicum, cantharides, chloroform (after administra- 
tion for anaesthetic purposes), duboisin, ergot, ferrous iodide, guarana, kava- 
kava, creosote, resin, castor-oil, ipecacuanha, hyoscyamus, lactophenin, 
matico, lead and its compounds, sulphur and calcium sulphide, veratrum 
viride, cocaine, conium, pimpinella, rhubarb, sulphonal, tuberculin, and va- 
lerian. 

Many of these drugs have been effective in but few instances. There 
is no reason why the list should not be in the future greatly enlarged, 
as it is probable that every medicament is capable of producing a 
temporary efflorescence when the system exhibits a special sensitiveness 
to its action. 

The Diagnosis of the various medicinal rashes described above does 
not, fortunately, demand a recoguition of the essential peculiarities 
impressed upon each by the exciting cause, since in many cases such 
peculiarities do not exist. The same drug may, on the one hand, 
produce a rash with symptoms widely differing in a group of 
patients, while, on the other hand, the urticarise resulting from the 
ingestion of " head-cheese/' quinine, and chloral may be indistin- 
guishable. But to establish the fact that a medicamentous eruption 
is present in any given case is a long step in the direction of reaching 
the precise cause that has been in that case effective. This informa- 
tion must often be obtained from the lips of the patient. The me- 
dicinal rashes are in general remarkable for their sudden appearance, 
their symmetry, their diffusion over large areas of integument, the 
presence of pruritus, the absence of fever, and their existence alike 
upon exposed and protected surfaces of the skin, thus hinting at the 
action of some cause not operating externally. Excluding syphilis 
and the exanthematous fevers, a generalized rash of sudden occurrence 
should always raise the suspicion of a dermatitis medicamentosa. 

1 New England Med. Jour., October 15, 1881. 



216 INFLAMMATIONS. 

Similarly in cases of preexisting cutaneous disease, syphilis, eczema, 
or psoriasis, the sudden occurrence of lesions of a new type widely 
diffused, or of rapid aggravation in situ, or of speedy extension in 
the area of those already in existence, should awaken the suspicion, 
if there be fever, of the exanthemata, and, without a febrile process, 
of the medicinal rashes. Thus, we have seen two patients with eczema 
exhibit rapid rise in body-temperature, and subsequently develop a 
generalized variolous rash ; and it is a matter of common experience 
to examine patients on the eve of a macular syphiloderm, or even long 
past the eruptive stage of that disease, showing their faces, necks, and 
shoulders covered with an acneiform rash produced by potassium 
iodide. The practitioner cannot too strongly be urged to view with 
exceeding watchfulness the skin of a patient affected with any of the 
common disorders (eczema, acne, and psoriasis) when the eruption 
becomes anomalous as to type, distribution, or symptoms. 

The medicamentous rashes, as a rule, disappear rapidly after the 
withdrawal of the exciting cause, and they require no further manage- 
ment. In some cases the soothing lotions, baths, and dusting-powders 
employed in the treatment of acute eczema may be required. 

It should not be forgotten that the patient who exhibits these lesions 
is usually one who has been suffering from the real or fancied disease 
for relief of which the drug was taken, and that condition may require 
recognition and management. 

In Morrow's treatise it is shown that the same drug may produce 
a variety of eruptive phenomena, and that the same eruptive features 
may result from the ingestion of different drugs. He points to what 
he concludes to be the neurotic origin of many of these rashes, and 
believes that the proof is inconclusive that they are to any considerable 
degree brought about by elimination, through the cutaneous glands, of 
the noxious element introduced with the drug. Tilden, however, calls 
attention to the fact that many of these eruptive phenomena are of the 
nature of angioneuroses, similar to Trousseau's tache c£r£brale, requiring 
often increase in the irritability of the cutaneous vessels, with exuda- 
tion of serum, outwandering of blood-cells, and, in case of hemorrhagic 
lesions, some change in the vascular walls themselves. 

FEIGNED ERUPTIONS 

Are usually varieties of dermatitis (erythematous, bullous, traumatic), 
discolorations, or ulcers produced by acids, caustics, and other chem- 
ical agents, or friction, for the purpose of exciting sympathy, extorting 
charity, securing hospital comforts, transportation to city life, etc. 
The persons employing these devices are, as a rule, criminals, hysterical 
young women, mendicants, soldiers, sailors, or servants seeking release 
from service. The extent to which hysterical women will go is well 
illustrated in one of the authors' cases, a young woman, who had 
suffered amputation of one finger and six months later asked to have 
the entire hand removed for a " gangrene," which disappeared under a 
fixed dressing, and which she afterward confessed was due to her 
applications of carbolic acid. The peculiarities, briefly, of these artifi- 



DERMATITIS GANGRENOSA. 



217 



Fig. 43. 



cial eruptions are : their odd appearance, not resembling the well-known 
types of ordinary disease ; their sharp definition, due to limitation 
of the disease to the area of contact of 
the article employed in its production ; 
their occurrence on parts most accessible 
to the hands and the eyes of the sup- 
posed victim of the disease, being in 
right-handed persons most percepti- 
ble on the anterior portions of the body, 
particularly over the surface of the right 
thigh or leg, and over the left arm or 
shoulder ; evidence of drops where a 
caustic liquid has been spilled over the 
surface, or of angularity in outline, due, 
as a rule, to downward flow of a fluid 
from above ; and staining of the fingers 
or nails, or of the tissue beneath the 
latter, by the operator. In a suspected 
case the diagnosis may be made clear by 
covering the affected areas with a plaster 
or other fixed dressing, since the artifi- 
cial eruption quickly disappears when 
the patient is prevented from making 
the effective applications. 

Many cases of dermatitis gangre- 
nosa and erythema gangrenosum have 
proved to be produced artificially by the 

patients themselves. Other diseases have thus been imitated. Among 
them may be named : sycosis, favus, alopecia, ringworm, scabies, 
bromidrosis, hsematidrosis, chromidrosis, erysipelas, abscess, and 
syphilis. 

" Chronic Pustulak Dermatitis with Extension in Periph- 
eral Patches " has been described and figured by Hallopeau. 1 The 
trunk and the thighs were extensively covered with large deep-brown 
plaques, having definite borders, and exhibiting here and there over 
the integument indurated projections of the size of a thumb-nail. The 
elementary lesion was a vesico-pustule with a red areola, which spread 
centrifugally by multiplication and which eventually became covered 
with a crust. 




Feigned eruption. 



DERMATITIS GANGRENOSA (SPHACELODERMA). 

Gangrene of the skin may result from a dermatitis originally due to 
the action of either excessive cold or heat ; to the action of externally 
applied chemical agents (caustics, strong acids, alkalies, etc.) ; or to 
shock ; to ergot and other substances ingested ; to infectious diseases 
(lepra, tuberculosis, syphilis, erysipelas) ; to central nervous disease 
(decubitus, Raynaud's disease) ; to disorders of the blood-vessels (embol- 

1 Int. Jour, of Rare Skin Diseases, 1890, iii. 1. 



218 INFLAMMATIONS. 

ism, thrombosis, acute and chronic endarteritis obliterans, calcareous 
changes in the arterial vascular tunics) ; to compression of vessels by 
ligature, by tumors, or by inflammatory products. 

Multiple Gangrene of the Skin is reported as complicating 
typhoid fever (Hahl 1 ) and malaria (Osier 2 ). Hartzell 3 and others 
report cases in which the lesions were apparently auto-inoculable, and 
in which bacilli and cocci were demonstrated. It is possible that many 
cases are due to a local infection. 

Crocker describes two cases, one that of a male, the other that of a 
female patient, in whom, as a consequence of scarlatina or some poorly 
defined antecedent disorder, crops of pustules, followed by gangrenous 
sloughing, occurred in almost all parts of the body, one attack rapidly 
following another with rise of body-temperature. A pustulo-crusta- 
ceous lesion of the upper eyelids, with gangrene resulting in a small 
circular ulcer, is reported as occurring in two healthy children. 

Fournier describes " spontaneous gangrene of the penis " following 
pruriginous and other papules of the part which were scratched and irri- 
tated. The gangrenous change in this condition succeeds a dull-reddish 
congestion of the part, including the mucous surface of the glans, fol- 
lowed by vesiculation, enormous tumefaction, and often by lymphan- 
gitis and erysipelas. 

Spontaneous Gangrene of the Skin occurs chiefly in hysterical 
female subjects, the affected plaques being irregular in outline and super- 
ficial or deep. After the slough has separated the plaques usually 
cicatrize without serious mischief resulting. Occasionally they spread 
as serpiginous lesions over the surface. Though doubt has been cast 
on these cases, in consequence of the discovery among them of feigned 
disease, it is certain that the malady occurs as described, without the 
operation of external agencies. These cases are included in those de- 
scribed elsewhere as Erythema gangrenosum. In making a diagnosis 
the feigned eruptions and their distinctive features should be kept in 
mind. 

Diabetic Gangrene has been described by Kaposi as occurring on 
the limbs of patients affected with glycosuria. Bullae appear, dry in the 
centre, and form black crusts, while new bullae arise at the periphery, 
thus producing a serpiginously spreading area with vesicular border, 
resulting in both dry and moist gangrene of the central parts. Similar 
cases are described by other writers ; in a few instances large portions 
of an extremity have been destroyed. Gangrene of fingers and toes 
without bullae is reported. 

Dermatitis Gangrenosa Infantum (Multiple Disseminated 
Gangrene of the Skin in Infants ; Varicella Gangraenosa ; Pemphigus 
Gangraenosus ; Rupia Escharotica ; Gangrenous Infantile Ecthyma). 

1 Amer. Jour. Med. Sci., 1900, 251. 

2 Johns Hopkins Hosp. Bull., 1900, p. 41. 

3 Amer. Jour. Med. Sci., July, 1898. 



SYMMETRICAL GANGRENE OF THE EXTREMITIES. 219 

— As a consequence of the exanthemata (variola, varicella, rubeola, pur- 
pura, erythema nodosum) the head, shoulders, and trunk of some 
children exhibit crust-covered lesions which ulcerate and finally throw 
off a gangrenous, split-pea- to small coin-sized, deep or shallow slough, 
after which repair commonly occurs. Severe losses are produced by a 
species of coalescence of smaller ulcers. 

These gangrenous points may occur beneath some previously exist- 
ing lesion or crust, or they may at the outset be spontaneous. In most 
cases there forms a vesicular lesion with rosy areola, that speedily 
bursts, leaving a blackish slough about which a circle of eliminating 
inflammation spreads. Thromboses result in the blood-vessels of the 
neighboring parts, oedema follows, and there is excited a train of re- 
active symptoms — fever, vomiting, diarrhoea, albuminuria, cardiac or 
pulmonary troubles. The patient becomes greatly emaciated. Crocker 
reports hemorrhagic vesicles and bullae in grave cases. 

Brocq is careful to distinguish between these grave forms of disease 
and those to which should be denied the appellation dermatitis gan- 
grenosa. In these milder forms vesicular lesions may develop, simu- 
lating those of varicella, occurring perhaps in crops and accompanied 
by a mild fever. Some among them may be covered with a blackish 
crust, may indurate at the base, surround themselves with an angry 
zone of inflammation, and, especially about the trunk, the thighs, and 
the anogenital region, ulcerate beneath the crust. Even though these 
ulcers coalesce and acquire a grave aspect, the result, as a rule, is not 
unfavorable. 

The subjects of this affection are infants and young children, from 
three months to several years of age. Beside the exanthemata which 
may precede, cases are on record as following tuberculosis, rickets, and 
syphilis. The process is one which, originally dependent upon the 
toxic effects of specific cocci, evidently requires a special soil for its 
effective operation. 

The treatment should include support of the general system, with 
local antisepsis by the aid of boric-acid solutions, aristol, iodol, and 
the dressing of the parts which slough by the usual deodorizing agents. 

The prognosis is at times grave. 

SYMMETRICAL GANGRENE OF THE EXTREMITIES (LOCAL 
ASPHYXIA, RAYNAUD'S DISEASE). 

This affection is usually first announced by the common signs of 
arrest of circulation in the capillaries, numbness, loss of sensibility, 
and color of passive congestion (local asphyxia, digiti mortui) in fin- 
gers and toes exposed to extremes of cold or of heat. The face, nose, 
ears, brows, and other regions and organs may also be involved. 
Eventually subjective sensations are awakened, stinging and lancinat- 
ing pains, pricking and crawling sensations. The parts involved, 
often the second and third phalanges of the digits, first become livid, 
then cold, firm, and black ; and gangrene of more or less of the af- 
fected tissue results, usually presenting the dry aspect. Bullae may 
form along the line of demarcation. Separation of the gangrenous 



220 INFLAMMATIONS. 

portions usually takes place slowly. The entire process may require 
but a few days or several weeks for its completion. 

Variations occur in a singular thinning of the digits, which may 
become indurated and slender ; or they may be covered with small 
whitish cicatrices where a superficial slough has separated ; or the 
parts may become cool, white like alabaster, and recover their tone 
without loss of tissue ; the nails alone may fall ; or indeed the entire 
process may meet with arrest in the early stage of blueness and asphyx- 
iation of the extremities. The mild forms which terminate in recovery 
may recur, and the type may become with each recurrence more severe 
until finally gangrene results. 

Etiology and Pathology. — This disease occurs equally in the two 
sexes and at all ages, and often in the cold weather of the winter 
season. There is a growing suspicion that many cases are of syphilitic 
origin, as the disease has followed specific infection. It has also suc- 
ceeded tuberculosis, diphtheria, the exanthemata, diabetes, and hsemo- 
globinuria. It is apparently due to trophic disturbances, the exact 
nature of which has not been determined. 

Treatment is by employment of the galvanic current, stimulation 
(as in dermatitis with congelation), and friction with stimulating alco- 
holic, camphorated, or oleaginous lotions. It is desirable to apply both 
electricity and (in some cases) dry cupping over the spinal region. 

The Prognosis is in some cases grave ; when the morbid condition 
is limited to a small part of the body recovery is often satisfactory. 

ERYSIPELAS. 

(Gr. epvdpog, red ; ireXka, the skin.) 

(St. Anthony's Fire. Ger., Eothlauf, Erysipel ; 
Fr., ICrysipele, La Kose.) 

Symptoms. — This disease is usually preceded by a prodromic 
period of malaise (lasting for twenty-four hours or less), which may be 
ushered in by one or several chills followed by febrile symptoms. The 
latter are accompanied by anorexia and often by vomiting with general 
depression and headache. 

The eruptive symptoms are generally first displayed at a given 
point, from which the disease progresses. It is commonly first noticed 
in a nut- or egg-sized patch, the integument of which is tumid, 
slightly elevated, irregular in contour, distinctly circumscribed, and 
presents a rosy or crimson-reddish color with a peculiarly smooth and 
characteristic shining or glazed appearance. The sensations awakened 
may be those of moderate pruritus, of pain, heat, or burning. To the 
touch the affected part is tender, moderately firm, and perceptibly 
hotter than normal. The color fades under pressure to a yellowish 
white. 

In typical cases the erysipelatous blush and swelling spread over 
an area which may be of the size of the palm, or may even cover 
the surface of an entire limb or a region of the body. In cases of 
moderate grade the inflammation attains a maximum of extent and 



ERYSIPELAS. 221 

severity within a week, remains apparently unaltered for a day or more, 
and then begins to abate, with amelioration of all the concomitant 
symptoms. The fever, which often precedes the eruption, continues 
unabated during its progress, the temperature rising to 105° or 106° F., 
with nocturnal exacerbation, cephalic and lumbar pain, dryness of the 
tongue, gastric distress, and occasional delirium. As involution of the 
disorder is accomplished the redness is replaced by the brownish, 
bluish-red, and dirty-white shades often seen after the disappearance 
of erythema multiforme, the epidermis finally desquamating in various 
degrees according to the extent of the preceding inflammation. 

In other cases, in which the exudation of serum beneath the epi- 
dermis has been rapid, the epidermis is raised in the form of vesicles, 
pustules, or bullae, more often the latter, and precisely as in the severe 
forms of dermatitis calorica, with which erysipelas presents a certain 
analogy, gangrene of the skin may result in the part affected. This 
complication is particularly liable to follow the disorder when it attacks 
the seat of surgical wounds and injuries. 

The febrile symptoms are, throughout, persistent and characteristic 
of a specific toxaemia. The body-temperature, as has been seen, may 
reach 105° to 107° F., with vespertine exacerbations and remissions; 
it may also become subnormal. If not relieved in the course of seven 
or eight days, complications may be expected, namely, oedema, abscess, 
phlegmonous inflammation, gangrene, or inflammatory accidents involv- 
ing the. membranes of the brain, lungs, heart, bowels, kidneys, perito- 
neum, or joints. 

Erysipelas Ambulans is a term used to describe that form of the 
affection in which the erysipelatous blush, after involving a given area, 
spreads with greater or less rapidity to the parts in the vicinage, either 
by direct extension and uniform advancement in one direction of the 
tumid and distinctly circumscribed border, or by linear, digital, or irreg- 
ular prolongations radiating from the inflammatory focus. As the 
blush and swelling advance in one direction there is usually a corre- 
spondingly rapid disappearance on the other. At other times the disease, 
while extending to a new area and abandoning the old, is relighted in 
the latter, and thus an irregularly involved and irregularly extending 
erysipelatous surface presents for weeks the varying phenomena of the 
disease. In yet other cases, chiefly those in which there has been a 
history of traumatism, a long erysipelatous linear streak or band may 
spread from the site of the traumatism in one direction or another, sug- 
gesting the indurated lines observed in lymphangitis. In severe cases 
the febrile, nervous, and other symptoms are grave, including coma, 
delirium, meningitis, and the signs of serious involvement of the lungs, 
pericardium, pleura, and bowels. Metastatic abscesses may also occur 
in the cutaneous and subcutaneous tissues, the joints, the peritoneal 
cavity, and even in the viscera. Death may result from these complica- 
tions, or from shock, exhaustion, or pyaemia. 

Surgical accidents aside, the face is the commonest seat of the dis- 
ease, on which the disease may be first seen upon one side of the nose, 
a cheek, a lip, or an eyelid. It often attacks the lobe of the ear after 
the operation of piercing the lobule for the insertion of ear-rings in 



222 INFLAMMATIONS. 

women ; thence it may extend over the whole face, inclusive of the 
mucous linings of the mouth and the nose, that present a dry, tumid 
and glazed appearance, suggestive of the symptoms displayed upon the 
skin. The inflammation may extend to the hairy parts, but in many 
cases it exhibits a species of reluctance to transgress the limits there 
presented. It maybe noticed in cases of mild grade, in which no appli- 
cations have been made to arrest a local progress, that the elevated 
border spreads symmetrically to within a few lines of the male beard 
or the hairs at the edge of the forehead, and there is- arrested. In 
severer grades these limits are surpassed, and then, as a rule, the 
extension is rapid and formidable. In this way the entire head may 
become enormously swollen, suggesting to a casual observer that it 
is twice its normal size. The patient then is greatly disfigured ; 
his scarlet lips are swollen and parted, permitting the escape of 
saliva ; the ears, as usual when greatly enlarged, project in a marked 
degree from the side of the head ; the eyelids are ©edematous and 
incapable of separation ; the face is disfigured by bullae or crusts ; and 
the mind disordered in the violence of the fever or the accesses of 
delirium. When recovery ensues the hairs generally fall. 

All regions of the body may be invaded, such as the vaccinated 
arm, the leg the skin of which is involved in venous varicosities, 
the scrotum or the umbilicus of the infant, the genitalia of the newly 
delivered woman, the breast of the nursing-mother, and every surface 
which has been the seat of punctured, incised, contused, or poisoned 
wounds, or other accidents of the integument to which the germs of the 
disease may have had access. 

• Chronic Erysipelas. — Habitually recurrent and indolent erysip- 
elatous attacks the identity of which with the disease here described 
it is difficult to establish, have been noted by several authors. The 
diagnostician is often consulted in cases in which an erythematous 
eczema of the face, an acne rosacea, a symptomatic erythema, or 
an acute inflammatory oedema is described as chronic or recurrent 
" erysipelas." The lesions to which such terms are restricted by care- 
ful writers, however,. are often forms of chronic dermatitis, such, for 
example, as occasionally follow dermatitis calorica. Instances occur 
in which the face, wholly or in part, is the seat of a low grade of in- 
flammation with local heat, swelling, redness, considerable infiltration, 
and some tenderness, the skin being irritable and worse after exposure 
to a high wind or after excesses at the table. But most of such cases 
fail to exhibit the distinct imprint of erysipelas ; they are not only 
chronic in course but are exceedingly indolent, often lasting for years ; 
they are unaccompanied by fever ; they are distinctly limited in all 
accesses of aggravation to the same part of the face ; they are rarely 
characterized by a bullous efflorescence ; many occur in the subjects 
of chronic alcoholism ; and the specific germs of erysipelas are not 
present. 

Etiology. — Erysipelas is caused by the streptococci of Fehleisen, 
which gain admission to the tissues through some lesion of the sur- 
face. The site of infection may be a surgical or other wound, or it may 



ERYSIPELAS. 223 

be a slight scratch or an unrecognized abrasion of the skin or mucous 
membrane. 

In the face, catarrhal and ulcerative processes involving the mucous 
membrane of the mouth, ears, and nose are often the cause of erysip- 
elas, these processes occurring in a wide range of disorders from syph- 
ilis of the nasal bones to caries of the teeth. Tuberculous and other 
ulcers, as well as eczema and several skin-diseases, frequently furnish 
a means of ingress to the streptococci. Injuries of, and surgical opera- 
tions upon, the scalp not conducted with antiseptic precautions, and 
the common piercing of the lobe of the ear in women and female 
children for the insertion of ear-rings, may be followed by the appear- 
ance of the disease upon the scalp, as a result of which the hair often 
falls Fistules, vaccination, lesions of the tender umbilicus of the 
newborn infant, and railway accidents may be named as common causes 
of the disease in other regions. 

Predisposing causes of this disease are to be sought for in cachexia, 
general debility, alcoholism, kidney-disease, epidemic influences, trau- 
matism, violation of hygienic rules, and occasionally the recurrence of 
previous attacks. Besides these causes, it is alleged that constitutional 
predisposition and particular articles of diet (mussels) may be responsi- 
ble for the disease. 

Since the malady is invariably the result of infection due to the 
presence of a streptococcus, the essential cause lies in the specific germ, 
in the absence of which none of the predisposing causes named can be 
effective. It is clear, however, that the predisposing causes suggested 
are those in which the multiplication of such germs and their entrance 
to the general economy are most facilitated. 

Pathological Anatomy. — Under the microscope the skin and sub- 
cutaneous tissues are seen to be infiltrated, the exudate being more 
serous and less rich in protoplasm than that observed in ordinary 
phlegmonous inflammation of the skin. The bullae represent rapid 
exudation of this same serosity to the congested epidermis, and the 
elevation of the latter in consequence. The elements of the rete and 
connective tissue are for the same reason swollen, the lymphatic and 
i blood-vessels are enlarged, and the cutaneous follicles are engorged, 
1 the root-sheaths of the hairs being occasionally separated, thus neces- 
sitating temporary loss of the pilary growth. In proportion to the 
severity of the exudative process pus-corpuscles may appear, and 
, represent, for the most part, degenerative changes in the subcutaneous 
! tissues resulting in abscess. The phenomena are, in short, those of 
superficial or of deep-spreading dermatitis. After death the skin which 
has been the seat of the disease cannot be distinguished microscopically 
from that of another part of the body. 

Unna, whose examinations were made largely in the skin of 
! children and infants, found invariably a simultaneous invasion of 
both the cutis and the hypoderm in erysipelas, the former recovering 
far more rapidly than the latter, and rarely reaching such a grade 
/ of activity. The venous capillaries were all enormously distended, 
as if paralyzed by the poison present, and the collateral lymphatics 
with the lymph-spaces were equally dilated. All the cutaneous ves- 



224 INFLAMMATIONS. 

sels swarmed with streptococci, both in the central and the marginal 
zones. 

Diagnosis. — Erysipelas is to be distinguished from the erythemata, 
from dermatitis of various grades, from eczema, and from scarlatina. 
As a rule, its recognition is readily effected when the presence of 
the fever in erysipelas is kept in view, as also the peculiar shining, 
swollen, and rosy-reddish to damask hue of the affected parts. The 
redness is never produced, as in scarlatina, by multiplicity of reddish 
puncta, nor is it so widely diffused as in that disease. Erysipelas may 
at times be accompanied by a pruritic sensation, but the patch which it 
affects is never by any possibility scratched. By this simple test alone 
one may often distinguish an erysipelas of the face from an eczema of 
the same region in a child. From a chronic dermatitis with thicken- 
ing of the affected tissues and redness of the surface, erysipelas is to be 
distinguished by its tendency to spread, by its acute course, by its fre- 
quent association with bullous or vesicular lesions, and by the color, 
outline, and raised border of the affected patch. However, it must be 
understood that to these localized patches of chronic dermatitis several 
authors have given the name " chronic erysipelas/' the difference 
between the views held on this point being chiefly one of titles. 

Treatment. — The method of treating erysipelas by the administra- 
tion of the tincture of iron internally has long been popular among 
American practitioners, but its efficiency is questionable. This prep- 
aration is given in full doses, from 10 to 50 drops, day and night every 
two to three hours, irrespective of the febrile state. 

The constitutional treatment is important, but is solely symptomatic, 
and should be directed to lowering the temperature, to obtaining proper 
functional activity of all the organs of the body, and in prolonged 
cases to sustaining the strength of the patient. Locally, when the 
erysipelatous blush has a distinctly circumscribed outline, an annular 
zone extending for an inch or more in width upon the sound and 
affected skin may be either covered with tincture of iodine, or be 
pencilled with a crayon of argentic nitrate, or be painted with a saturated 
solution of the same salt. The purpose of such treatment is to limit 
extension of the disease. It is true that these measures will not 
always succeed, but it is erroneous to assert with some authors that 
they always fail. Certain it is that, whether effective or not in the pro- 
duction of the result, the advancing border of the disease will often fail 
to surpass the limits thus artificially described. Collodion has been 
employed for a similar purpose, and Darlin x advocated the revival of 
this method of treating the disorder, basing its claim on the fact that 
the dressing diminishes the temperature of the part thus protected, and 
that, by the compression excited, it interferes with septic absorption. 
Heppel 2 recommends the painting over the surface of a 10 per cent, 
solution of carbolic acid in alcohol, as an abortive treatment, for which 
Braithwaite 3 substitutes a solution of tannin of the same strength. 

Good results have been reached in the local treatment of erysipelas, 

1 Bull. gen. de Ther., 1881, vol. ii., p. 239. 

2 Arch, of Derm., April, 1881. 

3 Brit. Med. Jour., April, 1881. 



ERYSIPELAS. 225 

first, by attempting to limit the extension of the disease by the applica- 
tion of the tincture of iodine over the peripheral zone, and, secondly, 
by retaining over the entire surface affected neatly applied compresses 
saturated with a solution of sodium hyposulphite in the strength of 
about 1 drachm (4.) to the ounce (32.). 

Attempts, however, to limit extension of the disease by local 
applications of an irritating sort (corrosive sublimate, silver nitrate, 
carbolic acid, tar, turpentine, etc.) are by most experts condemned as 
positively injurious. Dry heat applied by the aid of cotton or wool, 
cold compresses, or iced lead-lotions with intermissions of application, 
salicylic acid, boric acid, iodol, resorcin in solution, or iodoform in 
powder may be used. A 95 per cent, alcohol or a saturated solution 
of boric acid often gives good results if painted frequently over and for 
an inch or more beyond the affected area, or if applied on compresses. 

Koch applies 1 part of creolin, 4 of iodoform, and 10 of lanolin, cov- 
ered with gutta-percha. Nussbaum uses ichthyol and collodion, or equal 
parts of ichthyol and vaselin covered with a 10 per cent, salicylic lint. 
Hallopeau praises 1 part to 20 of sodic salicylate in aqueous lotions 
upon folds of linen. Elliott and others strongly recommend ichthyol 
in lotions, in oils, or in ointments. It may be used in strength vary- 
ing from 10 to 50 per cent., and is kept constantly applied to the 
affected area and for some distance beyond it. Tabit claims to abort 
the disease with a 10 per cent, solution of iodol in collodion. Injections 
of antistreptococcic serum have been used with varying success. 

Erysipelas rarely attacks a patient in vigorous health. The large 
majority of all the subjects of the disease are either those who have 
previously suffered from manifest general ill-health, or who have been 
complaining of local ailments, trifling wounds, nasal catarrh, or surgical 
accidents. It is these precedent conditions which often demand special 
attention. 

It is needless to add that all surgical indications are to be fully met 
when they are present : pus is to be evacuated, crusts removed, and 
drainage secured. The physician and surgeon alike should never for- 
get that the disease is infectious ; that the patient is to be isolated and 
to be supplied with an abundance of pure air ; and that fomites, surg- 
ical instruments, and even the non-disinfected hands of attendants are 
capable of transmitting the disease. 

Finally, there are forms of erysipelas which are remediless ; they 
are usually septic in character. The scarlet blush spreading from an 
irreparable injury of long duration is often the last protest of Nature 
against the damage which even her final resort of gangrene will not 
avail to repair. 

Prognosis. — Under favorable circumstances erysipelas, even of 
severe grade and extensive invasion, terminates in complete resolution. 
Reserve should be made, however, in every case, as a serious compli- 
cation has often transformed the simplest into the gravest form of the 
disease. The very young, the cachectic, the victims of drink, the 
aged, the inmates of hospital-wards depressed by other illness, and 
those mentally distressed by destitution and neglect, are particularly 
liable to suffer from grave and fatal forms of the malady. 

15 



226 INFLAMMATIONS. 

The patients who fill the beds in most lying-in hospitals are young 
women, either unmarried or deserted by their husbands, and unpro- 
vided with the necessities of life by those upon whom such a respon- 
sibility rests. The mental depression thus originating in connection 
with septicemic influences is responsible for much of the relation 
which erysipelas often seems to sustain to the puerperal state, as also 
for the appalling mortality which it may exhibit under these circum- 
stances. 

ERYSIPELOID. 

(Erysipelas Chronicum, Progressive Phlegmon, Erythema 

Migrans.) 

This term is employed by Rosenbach l to designate a special inflam- 
mation of the integument occurring as a complication chiefly of trau- 
matisms. When a wound is infected with the special poison of the 
disease a peripherally spreading tumid and empurpled halo encircles 
the site of infection, which slowly disappears in the part originally at- 
tacked while it extends progressively to another area. The advancing 
border of the disease is distinctly circumscribed, and may be festooned 
or scalloped. New points may appear from which the violaceous red- 
ness spreads, while others are in a state of apparent inactivity. 
This affection may be complicated with furunculosis, but scaling is said 
never to occur. Itching and burning sensations are usually present. 

Rosenbach believes that the source of this disease is a micro-organ- 
ism of the order Cladothrix, existing in putrid flesh and cheese, from 
pure cultures of which organism he is reported to have induced the 
disease. His position, however, is unfortified by experiments of other 
observers. 

The disease affects chiefly the fingers and hand (according to Elliott, 
also the scratched toes) of scullions, meat-dressers, fish-dealers, poul- 
try-cleaners, and persons of similar occupations. The distinction be- 
tween this disorder and erysipelas is based chiefly on the indolence of 
the former, its more superficial involvement of the skin, and the absence 
of constitutional symptoms. It is to be carefully distinguished from 
Crocker's " dermatitis repens " (some instances of which may be here 
included), from erythema multiforme, from erythema iris, and from 
ringworm of the hands. 

Treatment is efficient with local application of formalin, ichthyol, 
resorcin, pyoktan in-blue, pyrogallol, potassic permanganate, or the mer- 
curials in salves or in lotions. 

FURUNCULUS. 

(Lat. furunculus, a petty knave.) 

(Boils. Fr., Clou ; Ger., Blutschware.) 

Furunculosis is characterized by the occurrence of one or more cir- 
cumscribed cutaneous or subcutaneous abscesses, called " furuncles," 
which usually terminate by necrosis of tissue in the centre of the 
1 Verk. d. Deutsch. Cong. f. Chirurg., 1887. 



FUBUNCULUS. 227 

phlegmon, the expulsion of the necrotic mass in the form of pus or a 
core, and a resulting cicatrix. 

Symptoms. — Furuncles commonly begin as tender and painful 
indurations in the skin or its . subjacent tissues, the summit of each 
nodule soon becoming visible in the epidermis as a reddish punctum. 
A furuncle is the result of an active inflammatory process, limited to 
a definite area, and of greatest intensity at the centre of the involved 
mass. This centre is often represented by a hair-follicle, the pustule 
that forms subsequently being perforated by a hair. 

More or less rapidly thereafter these symptoms are succeeded by 
increased redness, heat, and tumefaction, the latter producing a nut- 
or egg-sized tuberosity, well projected from the surface or fairly im- 
bedded within or beneath the derma. A yellowish point in the centre 
of the erythematous swelling soon announces the occurrence of suppu- 
ration. When accidentally or artificially opened at this summit exit 
is given to thick yellowish pus with which blood may be commingled 
from the traumatism of neighboring capillaries. The small abscess 
may then, after discharging for a few days its purulent contents, grad- 
ually close by granulation, or may also expel from its cavity a tenacious, 
pus-covered, yellowish-green slough, known as the " core." This evac- 
uation is usually followed by relief of the tense and throbbing pain 
which is the well-known subjective characteristic of the furuncle. 

The length of time requisite for the completion of this process varies 
with the extent of tissue involved, from a few days to several weeks. 
Boils may occur in any part of the body, but are most common about 
the face, the auricular region, the neck, the armpits, the anogenital 
surfaces, the hips, the buttocks, the breast, and the extremities. They 
may occur as single or as multiple lesions, or they may succeed each 
other in crops, especially about the buttocks, trunk, and thighs, for a 
period of several months. It is this succession of boils to which the 
term " furunculosis " is specially applied. The disease of the skin, in 
patients suffering from furunculosis, may produce a constitutional effect 
manifested in pyrexia, which is usually encountered only in individuals 
of irritable constitution when the furuncles are few and short-lived. 
There is also a decided chloro-anaemia due to the pain, fever, purulent 
drain, irritability of nervous centres, inappetence, and consequent per- 
version of nutrition. 

The sequels of boils are maculations of a violaceous tint, often per- 
ceptible in the skin for weeks and even months after their disappear- 
ance ; and pinhead- to penny-sized cicatrices which are permanent. 

Etiology. — The microbe which is the immediate cause of boils is 
the staphylococcus pyogenes aureus. The remote cause, however, is 
often exceedingly obscure. It is true that boils are encountered in 
typical subjects of diabetes, of the exanthemata, and of " hospitalism," 
in whom anaemia, asthenia, marasmus, malnutrition, and exhaustion 
resulting from excesses, from grave general disease, from low fevers, 
and from nervous strain, play a prominent part. But the reverse is 
also true. 

Scratching, eczema, scabies, other cutaneous diseases, lice, and ex- 
ternal irritants of various sorts are responsible for many boils, especially 



228 INFLAMMATIONS. 

those that are few and not followed by similar lesions. When, how- 
ever, such sequence occurs it should not be forgotten that the pus is 
auto-inoculable, and that furuncles, if sufficiently numerous and large, 
are capable of disturbing the general economy. A collar-button at the 
back of the neck ; the edges of an unyielding corset in one unaccus- 
tomed to it ; a hard bench ; a saddle-tree ; a velvet coat-collar sheltering 
the germs responsible for a previous attack ; and many similar articles 
may be the exciting cause of furuncles. 

Account should always be had, in cases of persistent furunculosis, 
of externally operating poisons. In this category must be included 
sewer-gas emanations, arsenical wall-papers, and the poisons handled 
in the trades, e. g., by dyers, lead-manufacturers, etc. 

Lastly, it is exceedingly common for patients thus affected to apply 
to practitioners for remedies intended to "purify the blood"; and, in- 
asmuch as potassium iodide is often prescribed in response to this 
demand, the original trouble is thus enhanced to a manifold extent. 
Many cases of furunculosis are instances of boils resulting originally 
from external irritation, that have greatly multiplied and finally pro- 
foundly affected the system under the impulse of the so-called " blood- 
purifying" process. 

Pathology. — According to Unna, most furuncles begin with an im- 
petiginous lesion. Rarely is the hair-follicle the site of implantation 
of the cocci. After securing access to the rete these germs push before 
them the prickle-layer, flatten the papillary body, dig into the cutis, 
and later produce a perifollicular abscess of a lanugo hair-follicle. 
The abscess spreads by colonies of cocci which are swept laterally 
along the lymph-channels. Once in the subcutaneous tissue these 
micro-organisms find few barriers to their development and extension. 
They are found surrounded by dying pus-cells in the centre of every 
fat-lobule. 

Diagnosis. — Boils are to be distinguished from carbuncles by the 
aggravated symptoms of the latter. Circumscribed furuncular ab- 
scesses of the groins and the axillae are not to be confounded with 
suppurating, sympathetic, or virulent buboes of these regions, associ- 
ated with genital or extragenital contagious venereal sores. Errors 
of this sort have been made. Furuncles of the anal and genital regions 
in point of diagnosis may be significant of surgical affections of the 
neighboring parts (perineal, periprostatic, peri-urethral, and scrotal 
abscesses in men ; suppuration of the vulvo-vaginal gland in women, 
etc.). 

Treatment. — The debilitated constitution of many patients affected 
with boils indicates clearly the need of a tonic regimen, including the 
administration of iron, quinine, and strychnine, the mineral acids, and, 
contrary to the generally accepted opinion of the laity, a generous diet 
of milk, cream, eggs, and fresh meats. To these articles of diet wines 
and malt liquors may at times be added with advantage. Change of 
climate, of diet, of cooks, and of the habits of life is most serviceable in 
cases of prolonged furunculosis. The mineral waters at some health 
resorts prove especially valuable for the debility which often results 
from these disorders. The urine should always be examined for sugar, 



CARBUNCTJLUS. 229 

albumin, and an excess of urates. The internal remedies which possess 
reputation in this complaint are arsenic, sulphur and the sodic sulphites, 
the alkalies, tar, fresh yeast in tablespoonful doses, phosphorus, and the 
syrup of the hypophosphites of calcium, iron, sodium, and potassium. 

Calcium sulphide, which was once more highly esteemed than any 
other of the internal remedies named, is given in doses of -^ to i 
grain (0.0066-0.0133) every three or four hours. It is doubt- 
ful whether the drug exerts any influence whatever upon furuncles. 
In lithaBmia potassium acetate or citrate is given in large dilution, 
or the liquor potassse ; in gouty states colchicum, salol, and the 
alkalies, including the sodic salicylate. No one of these articles, how- 
ever, may be described as an efficient and certain remedy for the com- 
plaint ; many cases will progress without hindrance from any or all 
of them. 

Attempts in the direction of aborting a furuncle by the topical 
application of the stronger alkalies (aqua ammonise) or acids, caustics, 
cautery, ice, or premature complete excision with the scalpel, occasion- 
ally succeed, but often they fail. 

The best methods of local treatment are the simplest. The part 
may be frequently bathed with a hot, saturated solution of boric acid, and 
immediately after be covered with lint thickly spread with a paste 
formed of 2 drachms (8.) each of zinc oxide and powdered starch to \ 
ounce (16.) of vaselin; or with freshly made benzoinated zinc oint- 
ment. When the pain is unusually intense the parts may be dressed 
with charpie wet with hot borated lotions and covered with a protective 
dressing. When the pus is evacuated and the slough wholly or in part 
detached, the dressings for most cases, after washing with the hot borated 
lotion, are: boric acid in powder, iodol, iodoform (objectionable on 
account of its odor), aristol, or hydronaphtol (1 part to 100 of fullers' 
earth). 

Violent squeezing of a furuncle to separate its slough or to evacuate 
its contents should never be practised. 

Prognosis. — Eventually the worst cases are relieved when unac- 
companied by systemic or visceral disorders, and when the circum- 
stances of the sufferer permit him to pursue the most advantageous 
course (travel, diet, abstraction from business, etc.). The resulting 
cicatrices depend upon the severity of the process. Often they are 
( small and in the course of years become scarcely distinguishable ; in 
exceptional cases they are large, persistent, and disfiguring. 



CARBUNCULUS. 

(Lat. carbo, a live coal.) 

(Anthrax Simplex, Carbuncle. Ger., Carbunkel; 

Ff., Carboncle.) 

I A carbuncle is a circumscribed cutaneous and subcutaneous abscess, 
usually larger than a furuncle, that is due to the presence of staphylo- 
cocci, and is characterized by dense induration and sloughing, termi- 
nating in favorable cases by the production of a persistent cicatrix. 



230 



INFLAMMATIONS. 



Symptoms. — Carbuncles are often preceded by malaise, chill, and 
pyrexia of severe grades. There is commonly a burning pain at the 
site of the lesion. In cases in which the carbuncle is formidable and 
seated upon or near the head alarming symptoms of prostration, stupor, 
somnolence, and even coma, may be noted. With and without these 
concomitants a dense, dull-red, indurated, and painful phlegmon soon 
appears, varying in size from that of a small hen's-egg to that of an 
orange and even much larger, involving not only the skin but also 
the tissues beneath. Suppuration finally occurs, but the pus is not 
confined to a single space ; it undermines the integument and often 



Fig. 44. 




Vertical section of a carbuncle. Dense network of fibrous bundles, with interspaces communi- 
cating and extending to the subcutaneous tissue. (After Warren.) 

Fig. 45. 




f p mp 

Section of a carbuncle. Infiltrated papillae are seen at I, distended in balloon-shaped figures, 
between which the rete is compressed ; at p and mp columnse adiposse are seen ; /, division of 
elements, the fibrous bundles resolving into protoplasm. (After Warren.) 

through several apertures leaks out indolently to the free surface. The 
fenestrated or cribriform appearance of the skin covering the carbuncle 
constitutes in this stage one of its most striking features. Through 
these apertures may be distinguished the whitish or yellowish pus- 
soaked sloughs or portions of a single slough, which can at times be 
extracted through the orifice. Often the entire mass separates in a 
single slough involving the skin and subcutaneous tissues, leaving a 
crateriform ulcer of formidable size, which in favorable cases proceeds 
to heal by granulation. The resulting cicatrix is at first of a deep 
violaceous tint and later becomes blanched. It is indelible. 



CARMVmVLVS. 231 

The fever which usually accompanies this process may be mild or be 
severe, or, more commonly in dangerous cases, be of a typhoid char- 
acter. It results unquestionably from sepsis due to unliberated pus 
and necrotic tissue, and is naturally most grave in its consequences 
in patients weakened by previous asthenic disorders. Under these 
unfavorable circumstances the carbuncle may spread at the periphery, 
enclosing islands of necrotic tissue and ill-conditioned pus separated 
by bridges of empurpled, infiltrated, and yielding skin. 

The characteristic lesions of this disease most often appear on the 
back of the neck, the back of the trunk, and the lateral aspect of the 
hips and thighs, usually in a single development, though occasionally 
two or even three carbuncles of small or of medium size may coexist. 
The reason for their appearance in the localities named is clear. It is 
here that the skin is most thick and resistant, and, as a consequence, 
purulent foci when formed are covered in by the most voluminous 
layers of the connective tissue of the corium. 

Etiology. — Anthrax simplex is produced by the obscure causes 
to which reference has already been made as probably effective in the 
production of boils. Carbuncles and boils may coexist; or the one 
lesion may follow the other ; and there may occur intermediate forms 
assignable to either class. The disease is encountered more often in 
men than in women, and in later than in earlier life, simply because the 
tissues constituting its sites of preference offer in these individuals and at 
these ages a greater resistance to the exit of pus. The pus-cocci may 
sustain an etiological or purely an accidental relation to the lesion. 
Carbuncle is at times an epiphenomenon in cachexia, diabetes, albu- 
minuria, syphilis, pemphigus, and exfoliative dermatitis. 

Pathology. — The pathological anatomy of carbuncle has been well 
described by Warren, 1 whose observations conclusively show that the 
inflammatory process here is that seen in the simplest pustule. The 
special symptoms of carbuncle are due solely to the formation of the 
phlegmon beneath the dense and extremely thick masses of fibrous 
tissue found in the back "for the protection of that comparatively 
defenceless portion of the body." The cell-elements, multiplying with 
the intensity of the inflammatory process in the subcutaneous adipose 
tissue, pass upward along the fat-columns, crowd between these and 
push along the horizontal clefts branching from either side, infiltrate 
the derma, pass along the edges of the hair-follicles, fill the papillae 
until the latter "balloon" with pus, ooze to the surface through the 
cribriform aperture in the undermined epidermis, and macerate the 
bundles of fibrous tissue relatively intact that constitute the undetached 
mass of sloughing tissue. 

The constitutional symptoms in carbuncle (pysemic, septicemic, or 
sympathetic) are due solely to pus-imprisonment. The pus-formation 
is due to the presence of the staphylococcus pyogenes aureus and its 
toxin. Back of all lies the favorable soil (in the diabetic, the cachectic, 
etc.) for multiplication of the micro-organism. 

Diagnosis. — It follows from Avhat has preceded that carbuncle and 
furuncle differ solely in the depth of the starting-point of the phlegmon, 

1 The Pathology of Carbuncle, or Anthrax. Cambridge, 1881, p. 15. 



232 INFLAMMATIONS. 

and the density and resisting power of the overlying tissue. The car- 
buncle is, therefore, flatter, denser, less rapidly developed, larger, less 
tender, and more painful ; opens by many rather than by one or two 
apertures ; and is followed by larger sloughs, ulcers, and cicatrices, and 
occasionally by fatal results. 

Treatment. — Crucial and other deep incisions in the local treatment 
of carbuncle are certainly inferior in results to the course advocated by 
Wood 1 and Talor, 2 whose method is employed in cases with complete 
success, namely : a saturated solution of pure carbolic acid is injected 
with a hypodermatic syringe through the several apertures in every direc- 
tion into the sloughing tissues. When the orifices are not sufficiently 
numerous the point of the needle is thrust through the thinned integu- 
ment at the summit of the swelling at several points. The pain is 
severe but short-lived ; the tissues are blanched, indurated, and de- 
stroyed ; the slough in a few days is readily separated after division of 
its slender fibrous attachments ; and the ulcer rapidly contracts with 
the sequel of a smaller scar. It is necessary to use pure acid in satu- 
rated solution to prevent absorption of the injected fluid and the result- 
ing toxic effects. 

Relief is afforded in many cases by hot borated lotions and fomen- 
tations with the requisite skill in the surgical dressing of the parts, by 
carbolated lotions, extraction of the slough wholly or in portions with 
the forceps, and the subsequent employment of boric acid, iodol, iodo- 
form, or aristol, or the paste recommended in the treatment of furun- 
cles. An excellent method of withdrawing the purulent and sloughing 
contents of the carbuncle is to apply over it at the proper period an 
exhausted receiver, such as a common cupping-glass. 

Erasion of the entire abscess with a curette and subsequent anti- 
septic dressing is an accepted radical measure of relief for employment 
in proper cases. 

The antiseptic treatment of a carbuncle, however, furnishes the best 
results as regards the comfort of the patient and limitation of the 
disease. By this treatment there is absolutely no surgical interference 
with the lesion beyond the incisions made for the evacuation of pus. 
Violent squeezing and manipulation of the carbuncle are interdicted ; 
it is freely powdered with boric acid, iodol, or iodoform ; and on it is 
laid soft felt cloth thickly spread with any emollient and antiseptic 
salve, such as the ordinary zinc-salve. Boric acid in powder or iodol, 
thickly dusted over the carbuncle and covered with antiseptic wool, 
will also be found a useful dressing. 

Internally calx sulphurata may be administered in full doses ; it 
has, however, a questionable effect in diminishing the pus-formation. 

Other constitutional treatment may be demanded in furunculosis, 
including the liberal employment of tonics, a generous diet, a strict 
observance of the rules of hygiene, and stimulants when indicated. 
Pyrexic, septicemic, pyemic, and adynamic states require the special 
management of such complications, including cold sponging of the 
body-surface in fever, and the use of quinine, the mineral acids, and 

1 Toledo Med. and Surg. Jour., December, 1880. 

2 Australicn Med. Gaz., December 1, 1881. 



ANTHRAX. 233 

stimulants, with artificially applied heat in the algid condition. The 
urine should always be examined for sugar and albumin. 

Prognosis.— A serious issue need only be anticipated when the com- 
plications described above are grave in character or they occur in 
asthenic constitutions. 

ANTHRAX. 

(Gr. avOpag, a live coal. ) 

(Malignant Pustule, Splenic Fever Carbuncle. 
Fr., Pustule Maligne, Charbon.) 

Anthrax maligna is a carbuncular lesion resulting from infection of 
the skin or other organs of the body with a virus containing the 
anthrax-bacillus, furnished by an animal infected with splenic fever. 

This disease in man, fortunately rare of occurrence, results from 
external inoculation, and is always (See) derived from some animal 
affected with the specific malady variously termed " anthrax," " charbon," 
" splenic fever," " splenic apoplexy," or " Texas fever." After inocu- 
lation with the disease from an infected animal the human subject may 
(a) perish from systemic poisoning wholly septicemic in character with 
few external symptoms ; or, (b) when life is sufficiently prolonged, may 
suffer from visceral symptoms, and develop subcutaneous tumors ; or 
(c) may exhibit the symptoms of the disease now under consideration. 

In from twelve hours to three days after inoculation a painless macule, 
resembling a flea-bite, is first manifested, usually upon the dorsum or 
other part of the hands or the face to which the virus has had access. 
The macule is followed in from twelve to fifteen hours by an inflamma- 
tory and pruritic papule, which is rapidly transformed into a flaccid 
vesicle filled with a bloody serum and surmounting a firm indurated 
" nucleus " ; or a larger blood-filled bleb develops reposing upon a some- 
what painful, engorged, and often densely indurated base involving 
extensively the subcutaneous tissue. One or more similar lesions may 
follow in the surrounding integument, coalescence of which lesions pro- 
duces a large, angry, oedematous, and often gangrenous ulcer with a 
reddish areola. The area of skin involved may be of the size of that 
of a small coin or be as large as the palm of the hand. The lymphatic 
vessels and ganglia enlarge, become inflamed, and often suppurate ; 
metastatic abscesses form ; and the constitutional symptoms superven- 
ing are those described in connection with Equinia. If recovery is to 
ensue, the gangrenous mass will slough as in favorable cases of car- 
buncle ; if the result is to be fatal, the process is rapidly aggravated by 
cedematous infiltration extending to a wider area and by greater tissue- 
necrosis. 

In some cases the accompanying fever is high, with marked delirium ; 
in other cases it is of a typhoid character. Death results from shock, 
septicaemia, or exhaustion, though in cases in which the lesion is circum- 
scribed and unattended by constitutional symptoms recovery may 
ensue. 

Etiology. — This disease is induced by infection from one of the 



234 INFLAMMATIONS. 

lower animals, usually horned cattle, that suffer from charbon or 
splenic fever, and are handled by herders, ranchmen, etc. The sus- 
ceptibility of the carnivora to the disease is very much less than that 
of the herbivora. It is claimed that not only direct inoculation may 
produce the disease, but that it may be transmitted through the medium 

of flies and other insects. More recently it is 
Fig. 46. asserted that food, drink, and even inspired air 

I may be the medium by which the disease is con- 

# * veyed. 

—■ *"*^ CS5 Pathology. — Since the first investigations re- 

^ /%% #% ported in 1864 by Davaine to the French Acad- 

ia 9 *f em y> Pasteur, Klebs, Koch, Carnevin, and others 
/H# ^fJS* have demonstrated that splenic fever is solely 

\#^# 22? due t° the multiplication in the blood and tissues 

»""■ of a rod-shaped bacillus, the bacillus anthracis, 

Malignant pustule bacilli which is non-motile and transparent, measuring 
and o pus-cor P uscie S . (About frQm j to 1>5 fJ to 5 to 20 /jt . Under culture the 

bacilli may develop long filaments many times 
larger than the original rods, with a distinct sheath about a protoplasmic 
cylinder, which filaments after segmentation furnish oval shining spores. 
These spores have been cultivated in generations, with resulting germs 
that produced the disease artificially in the lower animals. 

The pathological anatomy of malignant pustule is that of carbuncle, 
with the added fact that specific bacilli and spores are everywhere 
present in the blood and debris of tissue. There is an almost char- 
acteristic oedema of the papillary body, according to Unna : the mar- 
gin of the epithelium is well preserved ; there is an acute vesicular 
elevation of the horny stratum without a previous breaking up of the 
connective-tissue layer, and this induces a stretching of all the cavities 
in a vertical direction. 

Diagnosis. — The characteristic features of typical malignant pus- 
tule are its central eschar, its crown of vesicles, and its indurated 
base. In establishing a diagnosis care must be taken to avoid one 
source of error. Malignant pustule in man is not of frequent occur- 
rence in America, but occasionally various cutaneous eruptions are pro- 
duced upon the hands after contact with animals or their hides upon 
which chemical solutions have been applied for the destruction of lice. 
These solutions usually contain arsenic, corrosive sublimate, or other 
substance capable of exciting a localized dermatitis. Chancre of the 
face, carbuncle, and poisoned wounds are all differentiated by their 
relatively indolent course and the absence of gangrene. 

The Treatment is to be conducted on the principles of general 
therapeutics. Deep incisions of the lesion, extended to the subcutaneous 
connective tissue, are often successful when practised before the occur- 
rence of general symptoms. 

Successful results have also been obtained from excision and iodo- 
form dressings. Hebra was not in favor of early cauterization of the 
malignant pustule, and it may be considered a questionable method of 
procedure. A grave case of malignant anthrax is recorded in which 
recovery ensued after hypodermatic injection of tincture of iodine. 



EQTJIN1A. 235 

Three syringefuls of pure tincture were deposited beneath the skin at 
the periphery of the diseased surface, and lint saturated with the same 
fluid was applied over the slough. Internally, 1 5 drops of iodine tincture 
(1.), with 3 grains (0.20) of potassium iodide, were also administered. 
Normal cicatrization followed in this and six other cases recorded. 

Crucial incisions with the free application afterward of pure car- 
bolic acid have been followed by good results. Internally, sodium 
hyposulphite and quinine are successfully employed. The febrile, 
typhoid, and adynamic features of the disease are to be treated in 
accordance with the recognized principles of general medicine. 

Prognosis. — The disease proves fatal in about one-third of all cases. 
Early excision gives promise of satisfactory results. 

EQUINIA. 

( Lat. equus, a horse. ) 

(Glanders, Farcy. Fr. y Morve, Farcin; Ger., Kotzkrank- 

HEIT, MALIASMUS.) 

Equinia is a contagious, virulent, and inoculable disease, transmitted 
to man from the horse, mule, ass, or other animal ; and produced by a 
bacillus resembling that of tuberculosis. It is conveyed either directly 
or mediately by the application of cloths and other articles which have 
been in contact with the bodies of infected animals. 

Symptoms. — The acute form of this disease commonly follows a 
period of malaise lasting a few hours or a few weeks, during which period 
the patient complains of vague pains of a rheumatoid type, followed 
by thermal variations. The body-temperature rises rapidly to the point 
of danger, with chills, fever, diarrhoea (often following constipation), 
and rapid exhaustion, the picture being suggestive of acute septicaemia. 

The cutaneous symptoms begin often with an erysipelatoid blush, 
the infected and swollen surface, also producing papules, vesicles, 
pustules, and bullae, with dense but ill-defined induration of the sub- 
cutaneous tissue ; or reddish and yellowish papules appear, which, as 
in the case of the fluid-containing lesions, coalesce and furnish a bloody 
discharge. These symptoms, in the case of inoculated disease, may 
develop on the site of the healed or healing wound of entry of the 
virus, and later become generalized. Sloughing ensues more or less 
rapidly, sometimes with extensive gangrene, though the patient often 
succumbs before the culmination of the morbid process. The lymph- 
atic vessels are swollen and well defined, often indurated. These symp- 
toms chiefly affect the face, hands, feet, and other exposed parts of the 
body. There is often a sanious or purulent and offensive discharge 
from the nostrils, the mouth, and the eyes, the inflammatory process 
spreading rapidly to the deeper mucous surfaces. This catarrh, chiefly 
nasal in site and declared conspicuously by the nasal voice due to the 
blocking up of the nostrils by the viscid, foul-smelling, hemorrhagic dis- 
charge, is one of the most characteristic features of the malady, and is 
of importance in the diagnosis. 

In the chronic form of the disease the nasal catarrh is less conspic- 



236 INFLAMMATIONS. 

uous at the outset, though later it may be a prominent feature of the 
malady. A few days or weeks after infection, pustules, as in the acute 
form, resembling those of variola, but flattened and never umbilicated, 
begin as vesicles or even as papules, coalesce to bullae, occur in succes- 
sive crops, and proceed to the production of multiple abscesses, poorly 
defined on the extremities and about the face, much more rarely de- 
veloped on the trunk. These abscesses may be of phlegmonous type ; 
or be deep, brawny infiltrations with purulent foci, extending over 
months of invasion and decline of the disease. From these abscesses, 
pea- to nut-sized over the face, larger on the limbs, flows an abundant, 
sanious, semiliquid or viscid, yellowish, offensive pus. Ulcers form at 
many points, with purplish borders, oval or roundish countour, and thin 
edges, suggesting the scrofulous ulcer of classical type. The edges may 
be soft or indurated. By this multiplication or coalescence the lips, 
nose, eyelids, and other parts of the face may in part or wholly be 
destroyed. The disease may steadily advance or may seem to be 
arrested for a time and reawaken to activity. Meantime the lymphatic 
glands are either unchanged or are enlarged by sympathy. In the 
course of months or years there is a fatal issue. The disease is, for- 
tunately, rare. 

Etiology and Pathology. — Equinia is almost invariably produced 
by infection from horses, a history of contact with such animals being 
one of the important points in establishing a diagnosis. The infection 
is produced by the glanders-bacillus (Weichselbaum, Schtitz,* Loeffler, 
Bouchard). This organism is nearly of the size of the tubercle-bacillus, 
having been cultivated and found capable of producing the disease in 
the lower animals after injection of cultures. The bacilli are abundant 
in papules, abscesses, blood, and brain-tissue. 

The Treatment is that of the septic condition, and is of little avail. 

The Prognosis is in the highest degree grave. 

DISSECTION-WOUNDS AND ANIMAL POISONS. 

Aside from verruca necrogenica, or anatomical tubercle, described 
in the chapter on Tuberculosis Cutis, lesions generally known as 
"dissection-wounds" occur with symptoms of acute poisoning upon 
the hands of those exposed in post-mortem examinations and dis- 
sections. At the inoculation-point, which may be either the site of 
a former abrasion, a rent, or the mouth of an open follicle, a painful 
vesico-pustule, papule, tubercle, wart, furuncle, or hemorrhagic bulla 
rapidly rises from an angry and indurated base with hypersemic areola 
of dull-red shade. Suppuration, crusting, or ulceration, limited to 
the seat of the lesion, may follow ; or there may occur lymphangitis 
in various grades with consequent pysemic or septicemic involvement 
of the system. Suppurative and non-suppurative axillary buboes are 
common. Gangrene and necrosis of the soft parts and the bones, espe- 
cially the phalanges, may ensue, as may also a fatal result from the sys- 
temic disorders named. Rarely an acute and fatal septicaemia may 
result when the lesion at the point of inoculation is so slight as to pass 
unnoticed. In a few cases chronic marasmus is induced. 



DELHI BOIL. 237 

The nature of the infection varies in different cases. It is most 
commonly due to pyogenic bacteria, but may be caused by the specific 
micro-organisms of tetanus, erysipelas, anthrax, or other infectious 
disease. The absorption of toxins resulting from the decomposition 
of animal tissues is undoubtedly an important factor in the infection. 

The treatment is to be conducted in accordance with the principles 
already described. Prophylaxis, by proper protection of the hands, 
and the immediate cleansing and disinfection of any accidentally 
wounded point, are of the highest importance. 

Pustules and other Lesions resulting from Wounds 
inflicted by Reptiles and Insects are often of an insignificant 
character. Such are the trivial results of the bites or the stings of flies, 
fleas, mosquitoes, ants, bees, hornets, etc. At other times, however, 
serious and even fatal consequences have been recorded. The wounds 
produced by the tarantula and the scorpion (which frequently lurk in 
the clusters of tropical fruit now imported to almost every part of the 
United States), as also of venomous reptiles, may prove to be grave. 
Urticarial, vesicular, pustular, papular, bullous, and petechial lesions 
may thus originate and be the cause of a more or less severe dermatitis 
with toxic symptoms. In the latter event it is common to administer 
as remedial agents alcoholic stimulants as freely as they can be ingested. 

DELHI BOIL. 

(Aleppo Evil, Biskra Bouton, Oriental Button, Oriental 
Ulcer, Gafsa Button, Natal Sore. Fr., Bouton d'Orient, 
Clou de Biskra.) 

This is a chronic contagious endemic disorder characterized by the 
occurrence of painful or painless nodosities upon the face, the hands, 
and other chiefly exposed portions of the body. The lesions are single 
or multiple, pea- to bean-sized pinkish papulo-tubercles, which in the 
course of three or four months become purulent and ulcerate indolently, 
or they become covered with crusts and scales. They are often 
grouped in patches and followed by characteristic cicatrices. The 
exact nature of the malady thus variously named is unknown. It is 
quite fully described by Fox, Farquhar, Pollack, Villemin, and other 
authors, as occurring in India, the region about the Euphrates and 
Tigris Rivers, and along the northern coast of Africa, especially Algeria 
and Morocco. 

Laveran * has described the Biskra bouton as occurring not only 
in Biskra, but also in the adjoining oasis. It shows itself as an 
endemic only in the months of September and October and continues 
until December, no new cases appearing in January and February. 
All ages, both sexes, the strong and weak, are liable to the disorder. 
The eruption affects the face and the extremities by preference, some- 
times also the trunk. It ordinarily attacks the same person but once, 
yet may recur. So long as the disease prevails the least excoriation 
has a tendency to become Biskra bouton. At first there is a reddish, 

1 Annal. de Derm, et de Syph., 1881, i., p. 173. 



238 INFLAMMATIONS. 

painless elevation of the skin, the size of a pin's head, that grows slowly, 
so that at the end of four or five months it attains the size of a small 
furuncle that is livid, sensitive, smooth, and boggy to the touch ; the 
centre of this elevation dries and a brownish rupioid crust forms, which 
is easily removable. Beneath this crust there usually forms a small 
round spongy ulcer, with ragged margin, ovoid contour, and ichorous 
discharge. The papules may occur in patches bearing thick crusts 
which long persist. The crusts are remarkably dry, and if undisturbed 
may eventually fall and leave no scar, though frequently ulceration 
progresses beneath the crusts. Healing is followed by the production 
of a permanent and deforming scar, the entire course of the disease 
lasting a year. 

The ulcers are usually single, but they may be multiple and may 
coalesce to form large ulcerating, granulating patches. They are usually 
irregular in form, with hard borders and soft red floors covered more 
or less with fungoid granulations and a thin ichorous discharge. 
Lymphangitis, erysipelas, and phlebitis occur as complications. 

Pathology. — Elliott, of New York, reports that the disease is 
limited to the epidermis and corium, and that its area is occupied by 
small round inflammatory or formative cells and epithelial elements. 
There is a distinct line of separation between the healthy and the dis- 
eased tissue. No cryptogamous or other micro-organisms have been recog- 
nized. The hair-follicles and other glandular structures are intact. The 
disease is contagious and inoculable and perhaps auto-inoculable. 

The horny layer is loosened ; the prickle-cells are multiplied periph- 
erally and centrally thinned or lost. Hyaline spheres and rounded 
masses are found between the cells of the infiltrated cutis. Leloir dis- 
covered an endarteritis obliterans. The cellular infiltration involves 
the entire cutaneous and subcutaneous tissue. The lymph-spaces are 
widely distended (Kiehl, Leloir, Duclaux). Unna regards the process 
as a chronic serofibrinous inflammation of the entire cutis with central 
necrosis, softening, and ulceration. Cocci have been found in zoogloea 
masses by Duclaux and Heydenreich, but no successful inoculations 
have been made with pure cultures. 

Treatment is not very successful, and often an expectant method is 
the best. In the majority of cases the ulcers should be treated on 
surgical principles with antiseptic and bactericidal dressings. Iodoform, 
tincture of iodine, silver nitrate in stick or in solution, and various 
preparations of the mercurials have been used with success. In some 
cases caustics, the cautery, or even surgical extirpation may properly 
be employed. 

Altounyan found the best treatment to be painting of the button 
with tincture of iodine, and that, as a rule, one attack conferred im- 
munity against a second. He believes the disease to result from the 
bite or the sting of an insect. 

Phagedena Tropica (Aden Ulcer, Malabar Ulcer). — Hirsch, 
Parke, and others describe a disease occurring chiefly among natives 
of the tropics, but also attacking travellers in tropical countries. It is 
rare in temperate zones : its victims are those chiefly who have been 



PHLEGMONE DIFFUSA. 239 

exhausted by fatigue, malaria, and malnutrition. In these cases a slight 
traumatism becomes later the seat of a vesicle or a bleb from which as 
a centre spreads a rapidly phagedenic sore extending by sloughs through 
skin, muscle, tendon, and bone. The disorder is usually first noticed 
on the exposed parts of the lower limbs, but other regions may earliest 
be involved. In mild cases there is arrest of the process before severe 
destruction is accomplished, and then cicatrization follows. 

The malady is aggravated by all unfavorable climatic and individual 
conditions. Microbes, supposed to be pathogenic, have been discovered 
by Boinet, who also cultivated these organisms and produced successful 
inoculations of animals. 

The treatment is precisely that employed for all similar surgical 
emergencies, viz., support by proper food and medicines; locally, anti- 
sepsis and parasiticides. The caustics employed by the French are 
inferior to effective parasiticides, such as borated, salicylated, and sub- 
limate dressings, and formaldehyd. 



PHLEGMONE DIFFUSA. 

(Gr. (pTieyfiovf], an inflamed tumor.) 

The word phlegmon is employed by most English and American 

writers to indicate a circumscribed cutaneous inflammation which ter- 

i minates naturally in suppuration, and which, as to the tissues involved, 

j is larger than an ecthymatous pustule, yet is not large enough to be 

I termed an abscess. Circumscribed phlegmons are represented by 

I most furuncles, and, at one stage of their career, also by carbuncles. 

In the disorder under consideration, however, the symptoms, both local 

and general, are far more serious than either furuncle or carbuncle. 

The disease is particularly prone to develop in children, especially 

I infants, and in women. The first evidence of trouble may be a severe 

j chill followed by high fever and a deep-seated hammering pain, felt in 

the part which is the seat of the disease. This site is soon recognized 

as an oedematous area, of dull-red or livid hue, tensely infiltrated, of the 

i familiar brawny type and indeterminate outline. All these symptoms, 

| which rapidly increase, as resolution is rarely attained, are followed by 

j suppuration at one or more points. In diffuse phlegmon, however, 

the brawny tenseness of the inflamed skin has been so great that, as a 

consequence, vascular thrombosis occurs and the circulation is greatly 

impeded between the points at which pus forms or about a single point. 

The tissues then become more or less necrotic, both during and after 

the formation and evacuation of pus. 

The fever meantime may abate or may entirely remit, or, in grave 
cases, may steadily persist. In the latter event the subcutaneous tis- 
sue, fasciae, periosteum, bones, joints, and ligaments may be involved. 
But in favorable cases the systemic condition is greatly improved 
when pus is no longer deeply or extensively formed, and when the 
gangrenous shreds and sloughs are well loosened or are entirely 
removed. 

The " acute purulent oedema " of English authors and the gangrene 



240 INFLAMMATIONS. 

foudroyante of the French may be regarded as severe types of diffuse 
phlegmon. In most of these grave cases patients die septicemic be- 
fore complete evolution of the cutaneous inflammation is reached. In 
other cases the affected part, suddenly losing its tense, brawny hard- 
ness, becomes emphysematous or crepitates with bubbles of gas pro- 
duced by decomposition. The patient may then become somnolent 
or delirious, or be the victim of an intercurrent and fatal involvement 
of the kidneys, lungs, liver, spleen, or bowels. 

The Treatment of diffuse phlegmon is largely surgical. Incision, 
drainage, and disinfection are the three essential requirements. These 
measures thoroughly assured, the systemic treatment is by quinine, 
stimulants when indicated, and the accepted remedies for the typhoid 
condition generally, including rest in the recumbent posture and a 
proper supply of wholesome air and food. Amputation of limbs may 
be necessary to save life. 

The Prognosis rests almost entirely upon the extent, diffusion, and 
severity of the local inflammation, and upon the systemic condition of 
the patient. In a previously healthy subject, with good hygienic en- 
vironment and the absence of thrombosis, pyaemia, septicaemia, and ery- 
sipelas, the result will generally be favorable. With the reverse of 
these conditions the outcome may be serious as regards the loss of a 
limb, deformity, or a fatal issue. 

SYCOSIS. 

(Gr. cvkov, a fig.) 

The title " sycosis " no longer indicates an idiopathic affection. It 
is employed in these pages to designate a group of different disorders, 
which, affecting for the most part the region of the male beard, may 
be for practical purposes classified as follows : 

Coccogenous Sycosis includes the most numerous of the cases to 
which the term " sycosis non-parasitica " was once given, and which are 
all due to invasion of the pilo-sebaceous crypts by pus-cocci. These 
pyogenic organisms may be either primarily or secondarily effective in 
producing the symptoms of the disease. In many cases a suppu- 
rative folliculitis follows the disorders included in the group last 
named. 

Bacillogenous Sycosis is described by Tommasoli. 1 

Hyphogenous Sycosis (Barbers' Itch, Ringwokm of the 
Beaed) is due to the presence of either the microsporon Audouini or 
the trichophytons (Teichophytosis Babb^:). It is described in this 
work among the Tinese. 

A group of Scab-leaving Sycosifoem Deematoses (Lupoid Sy- 
cosis, Ueeeythema Sycosifoeme, etc.) may also be recognized which 
differ somewhat from those named above. They include the pseudo- 
sycoses, the eczemas limited to the region of the beard with acneiform 
features, the eczemas of the same region with seborrhoeic complications, 
certain forms of lupus erythematosus of the beard, and the still rarer 

1 Monatsch. f. prakt. Derm., 1883, p. 403. 



COCCOGENOUS SYCOSIS. 241 

sycoses possibly due to tuberculous infection of pustular lesions of the 
bearded face. 

COCCOGENOUS SYCOSIS. 

(" Non-parasitic " Sycosis, Sycosis Vulgaris, Sycosis Staphy- 
logenes, Mentagra, Ficosis, Folliculitis Babb^:. Ger., 
Bartfinne.) 

Symptoms. — The lesions appear upon the face, involving one or 
both cheeks successively or simultaneously, the chin, the upper lip, the 
eyebrows, the scalp, the axillae, and the pubes. The disease, however, 
is almost always limited to the region of the beard in men. In this 
respect sycosis differs from acne and other disorders of the sebaceous 
glands of the face with which authors have sought to identify it, since 
not only is it, as a rule, strictly limited to the region of the beard, but 
also the non-hairy portions of the face of the patient are free from 
comedones, acne-lesions, and other symptoms of a cutaneous disorder. 

When seated upon the upper lip the first symptoms may be those of 
a nasal catarrh ; seated elsewhere an eczematous attack may precede 
the onset of the disease. It may be ushered in with the acute symptoms 
exhibited in the early stage of some forms of eczema, and with tume- 
faction accompanied by a sensation of heat and burning ; but often a 
few isolated and indolent lesions, the presence of which scarcely 
awakens attention, are the first traces of the disorder. Soon there may 
be recognized a larger or smaller number of discrete, pin-point to split- 
pea-sized, flattened or conical, reddish and painful papules, tubercles, 
or pustules, the anatomical seat of which is distinguished as the pilary 
follicle because of the penetration of each lesion by a filament of hair. 
These lesions may persist, and when typically discrete and visible at 
the part at which the hair makes its exit from the duct of the follicle 
they suggest the appearance of the surface of the fig, whence the disease 
derives its name. They are apt to occasion a burning and at times a 
decidedly pruritic sensation when, being picked or torn open by the 
fingers, the pus concretes into a crust at the base of the hair. In 
severer cases these lesions, while not coalescing, are so closely set 
together as to form a patch of continuous infiltration. These patches 
may be weeping or be crusted ; in the latter case the crusts are apt to 
be small and numerous, each crust being limited to the shaft of a single 
hair, and leaving when removed a minute crateriform excavation at the 
mouth of the follicle. 

Involution of several lesions may be followed by fresh crops, and, 
sooner or later, distinct patches of disease are thus formed. When 
fully developed the surface of the skin is reddened, swollen, infiltrated, 
and thickened ; covered irregularly with papules, pustules, crusts, and 
scales, and frequently with excoriations. The disease often lapses into 
chronic conditions, usually the result of improper treatment, and in 
ancient cases the deformity is characteristic and totally unlike that 
produced by the vegetable parasites. The hairs are usually fixed 
firmly in their follicles, but from those in which active suppuration is 
in progress the hairs may be plucked without occasioning much pain. 

16 



242 INFLAMMA T10NS. 

In cases which have been treated for years the hairs are thinned and 
decidedly lack vigor. 

In typical and neglected cases of long standing, in which the region 
of the beard is involved, an important clinical feature is the symmet- 
rical, general, and uniform involvement of the entire surface. The 
picture of one cheek is very nearly that of the other. The sparse 
hairs scarcely serve to disguise the reddened, tumid, painful surface 
beneath, which displays the severe lesions of the malady. Furuncles, 
abscesses, cicatrices, vegetations, and eczema of the ears may compli- 
cate the process. Sycosis is occasionally acute in its course, but is 
more often chronic and rebellious. A typically chronic and untreated 
case of the malady rarely terminates by spontaneous involution. 

The thinning of the hairs, described above as a consequence of 
long persistence of the disease, is far more characteristic than any 
distinctly resulting alopecia ; the latter, however, very rarely occurs, 
but is then remediless. The same may be said of resulting cicatriza- 
tion, which is one of the rarest consequences, and which is generally 
due to bacillogenous infection. 

The absence of certain symptoms in this disorder is as significant as 
is the presence of others. Adenopathy of the cervical glands is very 
rare, but when present it should awaken suspicion of another malady. 
The disease when of longest persistence as to time produces great 
un sightliness, but not the deep-seated, subcutaneous, small- or large- 
nut-sized nodules or tubercles, forming the " lumps " so characteristic 
of trichophytosis of the beard. Sycosis vulgaris is a disease of chronic 
course, which may endure for years and be characterized by relapses and 
aggravations, but is entirely curable ; it is only in neglected and im- 
properly treated cases that such persistence may be expected. 

Scar-leaving Sycosiform Dermatosis (Lupoid Sycosis, Ulery- 
thema Sycosiforme, Seborrhee depilante). — Under these titles 
has been described a somewhat rare affection of the skin of the bearded 
face in men, the symptoms of which at the outset are practically those 
of sycosis vulgaris. In the course of the disease, however, whether in 
consequence of an added infection or as the result of the evolution of 
the malady, a change occurs in which the hair-follicles atrophy and 
considerable scarring results. The scars are often irregularly depressed 
between ridges and linear elevations of the surface. By Unna this 
dermatosis is grouped with a class of disorders to which he has given 
the title of " ulerythemata." It is possible that the disease may be 
eventually recognized as a tuberculous complication of ordinary syco- 
sis or one dependent upon the toxins of tubercle-bacilli. The course 
of the affection is exceedingly chronic, lasting, with alternations of 
improvement and aggravation, for several years. According to 
Robinson, the inflammation in these cases spreads peripherally upward 
or downward with a narrow infiltrated margin. The lesions outside of 
the follicles may be papular, vesicular, or pustular in type. The 
tendency to extension from a given centre and to irregular scarring are 
the chief characteristic features of the malady. 

Many of these cases strongly suggest in their features the symptoms 
of lupus erythematosus. In some instances the two affections are 



COCCOGENOUS SYCOSIS. 243 

indistinguishable. The malady is exceedingly obstinate and often 
requires severe local treatment. 

Etiology. — Sycosis vulgaris is unquestionably due to either primary 
or secondary invasion of the pilo-sebaceous follicle by micro-organisms. 
Obviously in many cases there is a special reason for the accessibility 
of the germs to the crypts where they are lodged. Shaving, and the 
use in common of towels, brushes, combs, etc., in public establishments 
(club-houses, barber-shops, hotels), and the employment of pillows, 
lounges, and reclining-chairs in public resorts are often the origin of 
the mischief. 

The disorder is encountered chiefly among men after puberty, and in 
those of all social conditions and grades of health. It is not transmis- 
sible by heredity. The mere performance of shaving is not known to 
produce it. At times the immediate cause of the disease is recognized 
when the upper lip is constantly irritated by a discharge due to profuse 
nasal catarrh. In other cases, again, all the causes of eczema may be 
invoked in explanation of the result. 

A careful study of many cases suggests that the hairs themselves are 
among the aggravating causes of the disease and the sources of its 
peculiar obstinacy. In health the motions of the free shaft of the hair 
do not irritate the follicle in which it is set ; in conditions of disease 
it is quite different. Each free hair operates like a lever upon the inflamed 
ring-tissue which encircles it on its escape from the follicle beneath, 
and thus by the touch of the hand, by the action of brushing, by cur- 
rents of air, or by any agency whatever, movement may be imparted 
to it. Every such movement teases to a variable degree the previously 
irritated surface beneath ; and when estimate is made of the hundreds 
of such movements to which each hair is subjected during a period of 
twenty-four hours, the relative importance of this apparently insig- 
nificant factor may be appreciated. 

Pathology. — The disease is due to pyogenic cocci exciting an inflam- 
matory process, which, whether originally follicular or perifollicular 
in seat, may extend either toward or from the follicle. Sometimes 
extraction of the hair is followed by a drop of pure pus which exudes 
from the follicle, and the root-sheaths of the hairs are seen to be 
altered in consequence of the circumscribed follicular abscess. At 
other times the follicle itself is free from disease, and the exudative 
process has evidently expended itself upon the perifollicular or even the 
interfollicular tissues, in which case the papillary layer of the derma 
exhibits the usual phenomena of hypersernia, infiltration, and multipli- 
cation of protoplasm, with abundant vascular dilatation. 

According to Robinson, the disease always begins as a perifollicular 
inflammation, under the influence of which transuded serum penetrates 
the follicle. Maceration and eventual destruction of the root-sheath of 
the hair result with the ultimate production of pus within and without 
the follicle. The pus when the hair remains in the follicle, finds its 
way to the surface by breaking through the epidermis near the hair; 
occasionally exit is obtained between the shaft and the follicle-sheath. 

The hair-papilla usually escapes destruction, so that permanent 



244 INFLAMMATIONS. 

alopecia seldom follows. The sebaceous glands are occasionally involved 
and even destroy ed, but the coil-glands are affected in exceptional cases 
only. The hair, according to Unna, is closely encapsuled by horny 
cells which surround the neck of the hair-follicle, like a horse-collar. 
When pus is formed in the cutis, colonies of cocci spread from about 
the neck of the follicle into the cutaneous abscess and sometimes as 
deeply as the hypoderm. The cocci may also accumulate within the 
follicle. In total suppuration of the follicle the tightly packed cocci 
fill the hair-fissure, occupy the centre of the follicular abscess, and extend 
parallel to the skin on the under margin of the abscess. 

The micro-organisms recognized (by culture and reinfection) as the 
effective agents in the production of Tommasolr's bacillogenous sycosis 
were bacilli with rounded extremities presenting an elliptical or ovoid 
appearance. They measured 1.0 to 1.5 x 0.25 to 0.3 [i. The symptoms 
clinically resembled those of coccogenous sycosis. 

Diagnosis. — The most important consideration here is the distinction 
between the coccogenous and the hyphogenous diseases of the region of 
the beard, upon which point, naturally, the microscope finally decides. 
Still the clinical features of the two affections are quite distinct. The 
coccogenous form is recognized : (a) by the greater redness of the in- 
volved surface ; (6) by the extension of the disease in advanced cases to 
larger areas of symmetrical involvement ; (c) by the more superficial 
character of the lesions ; and (d) by the firm implantation of the hairs 
in their follicles in the earlier periods of the disease, their relative 
freedom in all cases from fracture, and the absence of stumps. The 
hyphogenous disease of the hairs is peculiar, in consequence of : (a) 
decidedly less redness of the surface attacked ; (6) the frequent limita- 
tion of the malady to a circumscribed area, or to several such, irregularly 
dispersed over a large region ; (c) the peculiar " lumpy, tubercular, 
nodular, and uneven " characters of the patch, upon which Duhring has 
laid significant emphasis ; and (rl) the earlier loosening of the hairs in 
their follicles, as also of the occurrence of fractured hairs and of stumps, 
exhibiting usually at the bulb unmistakable evidences of the nature of 
the disease. The malady is often mistaken for syphilis, chiefly on 
account of the unsightliness it produces ; but the pustular syphiloderm 
is very much less chronic in its course, is rarely limited for years to the 
face exclusively, and, when long persistent in one locality, is character- 
ized by ulceration and the production of very characteristic crusts. 

Eczema may complicate the coccogenous disease by preceding or by 
following it, but typical instances of the two disorders may be recog- 
nized by the occurrence, in the case of eczema, of a discharging disease, 
not usually limited to the region of the beard, characterized by a more 
intense itching, and with marked absence of the papulo-tubercular lesions 
described above. The lesions in eczema, moreover, are not invariably 
perforated by hairs. The shaven face affected with erythematous eczema 
is reddish in color, and desquamates, after full evolution of the disorder, 
without pustulation. 

Treatment. — In all cases of sycosis the essential and important step 
is the continued removal of the hairs which, as indicated above, are the 
chief sources of aggravation of the disease. This removal is best 



COCCOGENOUS SYCOSIS. 245 

accomplished by epilation or by shaving, which, though often painful 
at the onset, is soon well tolerated by the sufferer. The majority of 
patients, however, object to removal of the beard, far more on ac- 
count of the consequent greater exposure to view of the unsightliness 
induced by the disease (then no longer partly masked by the hairs) than 
on account of the distress occasioned by the operation. To these objec- 
tions there is but one response — the shaving is essential ; the deformity 
is rapidly relieved after its successful initiation ; the discomfort dimin- 
ishes with each repetition of the process. For the disease in patients 
positively refusing to have the beard removed, whose cases are so severe 
as to require it, the practitioner will do well to decline to be responsible. 
There is no limit to the tedious and obstinate course of the malady in 
the one case, and in the other the results are speedily satisfactory, often 
in the course of a few weeks. 

When there is much tenderness, pain, swelling, pustulation, or crust- 
ing, the hairs may first be clipped short, and a bland poultice of oil, 
elm-bark, or of bread and milk applied. The practice in Vienna is to 
substitute for the poultice strips of soft muslin or linen spread with 
diachylon ointment, firmly bandaged over the cheeks, chin, or lips for 
from twelve to twenty-four hours, after which a razor is passed over the 
entire surface. The integument which thus becomes visible is usually 
a reddened infiltrated area, with pustules, papules, pustulo-papules, and 
some crusts dispersed here and there over it. After exit is given to all 
I purulent collections this area is best treated by hot- water lotions, borated 
j or alkalinized, and then a bland ointment is to be applied at night and 
! a borated dusting-powder in the morning. Formalin lotions of the 
I strength of 1 to 2 per cent, are valuable in all stages of the disorder. 
( The subsequent treatment is largely that of eczema of equal grade of 
severity. In the more acute periods oleated lime-water, medicated with 
| calomel or with zinc oxide, -^ to 1 drachm (2.-4.) of either to the pint 
j (512.), may often be employed with benefit ; or for this application may 
,j be substituted 2 ounces (64.) each of linseed-oil, Castile soap, and 
paraffin, to the pint (512.) of aqua calcis. Later, the Lassar paste or 
ointments may be used, particularly cold-cream salve, to which may be 
! added either sulphur, zinc oxide, or, less preferably, one of the mercu- 
rials. Lotions of mercuric chloride, sulphur, alcohol, cologne-water, 
or iodated glycerin may be useful in stimulating indolent patches of 
infiltration. The treatment of these patches is indeed that of chronic 
eczema. 

Epilation is often essential for relief of the disease ; and in chronic 
cases severe methods have been employed, including the use of green 
j soap, tar, and cauterization with acetic and even with nitric acid. Era- 
sion with the curette is to be named in the same category. These 
measures have been employed in aggravated cases ; but as the disease 
I is certainly curable in a majority of patients without having recourse to 
these heroic methods, they are to be regarded in the light of a dernier 
ressort It is not necessary in the majority of coccogenous forms of 
I sycosis either to epilate or to employ caustics. By repeated and fre- 
quent use of hot borated water, formalin lotions, and the milder 
i stimulants, with constant shaving, the desired result is usually 



246 INFLAMMATIONS. 

within reach. Shaving should be continued for nearly a year after 
all traces of the disease have disappeared ; and it is a point of some 
importance to substitute for a fatty application a continuously applied 
borated powder as soon as the skin will tolerate the persistent use of 
the latter. 

Van Harlingen advises for acute cases a wash composed of \ pint 
(256.) of rose-water, to which 1 drachm (4.) each of precipitated zinc 
carbonate and zinc oxide in powder have been added, with 2 drachms 
(8.) of glycerin and dilute liquor plumbi subacetatis. .Veiel recom- 
mends a solution of pyrogallol (1 part to 50) for painting over the 
region affected, followed in the day by emollient cataplasms and in the 
night by diachylon or weak tannin ointments. Sycosis of other por- 
tions of the body is to be treated as described for the region of the 
beard. 

Internally, treatment, when indicated, should be of the kind de- 
manded by the condition of the patient. It is a matter worthy of 
special attention, however to purge every previously treated case of 
suspicion of artificial element, by withdrawing for a time all internal 
medication. The disease is so disfiguring that many patients swallow 
potassium iodide, arsenic, and other deleterious drugs for months before 
consulting one who is wiser than they in these matters. Exposure of 
the face to dust, smoke, wind, and other sources of irritation should for 
a time be avoided. 

In the hygienic management of these cases all use of tobacco and 
alcoholic beverages is to be abandoned. Even the drinking of hot 
tea, coffee, and stimulating beverages of other kinds is to be inter- 
dicted. The diet should be of the simple character recommended in 
eczema. Inasmuch as many patients suffer from a coincident nasal 
catarrh, hot baths should be exchanged for daily cold sponging of the 
body-surface, for patients able to endure the shock, followed by brisk 
friction with flesh-brush or with coarse towels. 

In acute cases it may be desirable to begin treatment with a brisk 
mercurial cathartic ; the alkaline diuretics advised by authors will, at 
least, do no harm if judiciously employed. The same may be said of 
calx sulphurata and minute doses of calomel in the pustular stages of 
the affection. But in other cases cod-liver oil and iron are demanded 
by the general condition of the patient, usually one of the class ex- 
hibiting the evidences of "hospitalism." No firm believer in the 
coccogenous etiology of the disorder will, however, expect by these 
measures alone to relieve the disease. 

Prognosis. — The disease is entirely curable, and will, in the large 
majority of all cases, either disappear entirely or greatly be improved 
by judicious treatment. The latter requires the personal supervision 
of the physician and close attention to details. 

In exceptional cases the disorder is exceedingly chronic and obsti- 
nate, and requires perseverance on the part of both physician and 
patient to attain the desired end. Relapses are of frequent occurrence, 
due usually to neglect of asepsis after apparent recovery. In a few 
very rare cases (lupoid sycosis, tuberculosis) there is cicatricial tissue 
left after repair. 



IMPETIGO. 247 

IMPETIGO. 

(Lat. impetere, to rush upon. ) 

(Ger., Krustenflechte ; Fr., Dartre Humide.) 

The researches of Bockhart and others have demonstrated that 
the symptoms once designated by the term " impetigo/ 7 as also those 
of furunculosis and sycosis, are simply the local results of infection 
with staphylococci and streptococci. The symptoms to which in dif- 
ferent cases these several names are given differ in consequence of the 
accidents of location, the sex of the patient, and the opportunities for 
extension of the disease. 

Hebra stated that, even in his day, the pustular cutaneous affection 
described by authors under the name " impetigo " had no existence as 
an independent disease. Unquestionably a long list of disorders hith- 
erto described under this term included, in fact, forms of pustular 
eczema. The reasons for retaining the name given above and for 
assigning to it certain peculiar eruptive features are based upon the 
simple tact that the lesions displayed, probably in consequence of the 
operation in a similar way of like causes, reproduce themselves again 
and, again, so as to exhibit the same clinical picture in different patients. 
The convenience of the name impetigo, as descriptive of a group of 
cutaneous symptoms, is therefore the sole reason for its retention. 
There is, however, among some dermatologists of the French school 
a tendency to consider impetigo a distinct disease and to distinguish 
several forms, each having a definite cause and capable of reproducing 
itself through inoculation. 

Symptoms. — The disease is not infrequently encountered, being 
observed chiefly in children and young adults of both sexes, though 
typical symptoms may be exhibited at any period of life. In such 
patients, from one to twenty or more isolated and often widely separated 
minute vesicles or vesico-pustules, superficial, without areolae, without 
induration, and usually acuminate, appear upon the skin-surface either 
simultaneously or in rapid succession occasionally after a slight access 
of fever. They are speedily transformed into split-pea-sized or larger, 
circumscribed, oval or circular pustules, so rapidly transformed, in fact, 
that often the early vesicular phase is not manifest, the lesions showing 
as minute pustules from the first. When fully developed they are 
globular, yellowish white in color, discrete, well distended with their 
puriform, rarely bloody contents, and projected clearly from the surface 
on which they rest. They may be surrounded by an erythematous 
areola, or simply be superimposed upon an integument of unaltered color. 
They may persist as pustules, or may burst, their contents drying into 
a yellowish crust resembling honey, or into brownish-tinted concretions 
which adhere with firmness to the superficial and circumscribed base, 
where a slight weeping can be determined. They run an acute course, 
usually terminating within a fortnight. They are much more commonly 
observed upon the face, but are recognized elsewhere, always sparsely 
upon the trunk and extremities. The eruption is never in any sense 
generalized, its characteristic feature being the fewness of the lesions, 



248 INFLAMMATIONS. 

which are scarcely ever grouped, and which occur in capriciously 
selected locations. The subjective sensations are slight, and the erup- 
tion is more often picked than scratched. The disease bears no relation 
to pustular eczema. It is common in dispensary and hospital patients, 
and since these are often the victims of neglect and the subjects of vices 
of nutrition it has been considered the appanage of scrofula. But the 
disease is also encountered in well-nourished and rosy-cheeked chil- 
dren ; in the latter, when well cared for, the eruption proceeds regularly 
to resolution, while in the former it is prolonged and often aggravated, 
thus attracting to a greater degree the attention of the physician. The 
pustules are never umbilicated, never seated upon ulcers, and are never 
followed by cicatrices. 

Impetigo Contagiosa (Poeeigo Laevalis, Poeeigo Contagiosa, 
Pemphigus Acutus Contagiosus Adultoeum (Pontoppidan), Im- 
petigo Contagiosa Bullosa). — In 1862 Tilbury Fox gave the name 
impetigo contagiosa to a group of symptoms which were by him sup- 
posed to be characteristic of a definite disease. These lesions are now 
recognized as those of impetigo. 

The eruption, occurring in infancy, childhood, and early adult life, 
may be preceded by a febrile process, and appears in the form of rarely 
numerous, isolated vesicles, vesico-pustules, pustules, or bulla?, usually 
about the face, but also upon the neck, the buttocks, the hands, or the 
feet. In severe cases these lesions are surrounded by an areola. The 
lesions are roundish, flat, have the average size of that of a split pea, 
and become covered in the course of a few days with dry, granular, 
straw-colored crusts which closely adhere to the slightly reddened base 
on which they rest. Beneath the crusts are to be discovered very 
superficial erosions which rapidly become covered with epidermis. 
They occasionally coalesce, and their complete involution requires from 
a week to a fortnight. When they are of the dimensions of bullae a 
pseudo-umbilication may be observed at the apex, produced solely by 
flaccidity of the roof-wall, which is never " guyed " down, as in variola. 
The contents of the lesions are inoculable and auto-inoculable, the dis- 
ease thus spreading from one member of a family to another, and also 
from one part of the body of an individual to another part. The 
mucous surfaces are occasionally invaded (impetiginous stomatitis). The 
subjective sensations are mild, the itching rarely being severe. The 
disease runs a tolerably definite course, being usually at an end in a 
fortnight ; it may recur. It may be, Kaposi states that it is at all 
times, accompanied by submaxillary adenopathy. 

Impetigo may be indicative of the symptoms of several widely dif- 
fering causes, all resulting in a coccogenous or hyphogeneous disorder. 
In some cases the irritation is set up by the encroachments of the tricho- 
phyton. In other cases there are pediculi of the occipital region, and 
the scratching set up in children in consequence of attacks of lice fur- 
nishes the opportunity for infection with staphylococci. In yet other 
cases the micro-organisms responsible for varicella have operated to 
produce the symptoms. 

The several clinical pictures differ on account of the greater or lesser 



IMPETIGO. 249 

diffusion of the contagious elements in each case ; for example, there 
may be a few isolated pea-sized and larger vesico-pustules on a single 
hand ; or many may be clustered about the moutli and lips ; or dense 
greenish crusts may succeed such lesions over occiput or scalp ; or 
there may be much larger pustulo-bullous elements over the legs, torn, 
scratched, and thickly crusted or covered with hemorrhagic incrusta- 
tions. In rare instances circinate, annular, gyrate, serpiginous, herpetic, 
variolaform, and even pustulo-crustaceous lesions have been observed. 
The disorder is not often seen in private practice, but in public patients 
it is seen among the cachectic, the filthy, and the neglected. 

Etiology. — The cause of impetigo is mixed infection with strepto- 
cocci and staphylococci ; often the one is grafted upon the other. The 
peculiarities of the cocci are the shortness of their chains, the slightness 
of their incurvations, their failure to interlace, and the irregular form 
of the elements of which the chains are composed. For these reasons 
an attempt has been made to disassociate, without result thus far, the 
germs of this disease from those found in the pus of other affections. 

The disease occurs rather at the age of childhood than in infancy and 
adult life, a period when the hands are first brought into habitual con- 
tact with the face, these quite suggestively being the sites of election. 
The lesions are rarely scratched, being more often torn with the nails in 
picking, so that the crusts may be somewhat blood-colored. The prac- 
tice of picking the nose and other parts of the face and the body with 
unwashed hands is the chief source of mischief. In later life the habit 
of refraining from carrying the hands to the face when the former are 
soiled becomes instinctive. Before this instinct is well established — that 
is, in childhood — the hands will convey to the head any particle of filth 
or of dust with which they may have been brought in contact. 

The somewhat obscure relations of the disease to varicella, variola, 
and other affections occurring in epidemic visitations have attracted 
the attention of many observers. The disease is one peculiarly prone 
to attack children and those in the humbler grades of life. 

The eruption often occurs during convalescence from a more or less 
actively contagious disease. The antecedence of some fever in many 
cases is admitted by all observers. Duhring and Fox have seen it 
follow vaccinia, and the former admits that some connection between 
the two seems probable. It may occur typically in a series of children, 
each of whom is convalescent from varicella. 

Pathology. — The lesions have been examined microscopically by 
Bockhart and others, who have thus been able to establish clearly the 
coccogen oils' origin of the disorder. Plainly, each lesion is but a dis- 
tinctly circumscribed and superficial pea- to bean-sized abscess, situated 
between the intact corneous and the prickle-layers of the skin. Balzer 
and Griffon 1 agree with Thibierge and Bezancon in asserting that almost 
without exception the lesions of impetigo and ecthyma contain strepto- 
cocci and no staphylococci. In some cases, however, the staphylococcus 
pyogenes aureus and albus are present. Larier and other French der- 
matologists describe an impetigo strepto-coccogenata circinata, in which 
the lesions closely resemble those of herpes iris, and in which the strep- 

1 La Presse med., 1897, 89, p. 130. 



250 INFLAMMATIONS. 

tococcus only is found. Leroux and others, recognizing the fact that 
many micro-organisms similar in external appearance have decidedly 
differing potentialities, have suggested that the streptococci responsible 
for the several clinical pictures of impetigo may differ in effect. 

In Unna's differential diagnosis of the impetigo- and eczema-pustule 
stress is laid upon the sero-purulent character of the contents of the 
latter, the dissemination of cocci throughout the lesion, the softening 
of the corneous layer in places, and the occurrence of morococci free 
and within the leucocytes. In impetigo the staphylococci. are clustered, 
are extracellular, are relatively small, and are clustered beneath the 
intact roof- wall of the lesion. 

Dewevre 1 reports a number of successful inoculations and auto-inoc- 
ulations practised with the contents of the vesico-pustule, with finely 
powdered impetiginous crusts, and with the products of scraping the 
subjacent erosion. In 1884 one of us succeeded in producing an 
almost typical vesico-pustule upon the left forearm by inoculation (all 
due precautions being observed) with the moistened debris of crusts. 
This inoculation was done in the clinic, the crusts being taken from 
typical lesions upon the face of a young girl inoculated while under 
observation from the lesions of exactly similar character on the face of 
her twin sister. The lesions on the forearm produced a characteristic 
crust which in seven days was also used for inoculation of two students 
then present at the clinic, in one of whom there was no result, and in 
the other an abortive lesion. 

The disease is contagious, and its lesions inoculable and auto-inocu- 
lable, whether as a coccogenous or hyphogenous process. 

Diagnosis. — To establish the identity of this affection it is neces- 
sary to define its exact differences from eczema pustulosum. These 
differences are : first, the absence of infiltration of the tissues affected ; 
second, the absence of itching ; third, the failure of the lesions to form 
patches ; fourth, the isolation and wide separation from one another of 
lesions distinctly pustular ; fifth, the large development and rather per- 
sistent character of the pustules ; sixth, the evident termination of the 
disease, which does not, as does eczema in many cases, progress to form 
a freely discharging and crusting surface, the pustular being but the 
initial stage of a distinct morbid process. Manifestly, however, an 
impetigo of the sort described is not incompatible with an eczema which 
is often originated by less irritating causes. 

In ecthyma the pustules are in appearance much more formidable 
than those of impetigo in consequence of their size, depth, inflamma- 
tory base, areola, flat hard bulky crust, and erosive action upon the 
skin. 

In varicella the lesions are small, much more widely distributed 
over the body, and are vesicular only, rarely bullous. In pemphigus 
and herpes iris the seat, character, and period of evolution of the lesions 
suffice to establish the diagnosis. 

Treatment. — Individual pustules are to be opened with an aseptic 
comedo-needle ; the purulent contents gently removed by washing with 
borated water ; and the floor smeared with any mild ointment, such as 

1 Arch, de Med. et de Pharm. mil., Sept. 16, 1885. 



ECTHYMA. . 251 

5 grains to \ scruple (0.33-0.66) of ammoniated mercury to the ounce 
(32.) of cold-cream salve, or bismuth subnitrate J drachm (2.) to the 
ounce (32.), or benzoated zinc salve. Van Harlingen recommends the 
application of a salve on bits of muslin, covering the whole with waxed 
paper. A dusting-powder containing calomel may be substituted for 
the salve or be employed afterward. The disease tends to spontaneous 
recovery if the lesions be not irritated. When they are situated within 
reach of a child's tongue which is constantly thrust out to moisten them, 
they may linger obstinately and require protection by flexile collodion. 



ECTHYMA. 

(Gr. endvfia, a pustule ; sadva), I burn out. ) 
(Ger.j ElTERPUSTELN.) 

The term " ecthyma," like several of the titles of chapters imme- 
diately preceding, no longer points to a distinct disease. It represents 
rather a tolerably definite group of symptoms readily separable clin- 
ically from other affections produced by different causes. The most 
common cause is infection of the skin of the lower extremities with 
pus-cocci after scratching ; then follow traumatisms, primary and 
secondary, associated with pediculi of the body (pediculus vestimenti), 
and combinations of these with bedbug-bites ; general filthiness of 
the person and clothing of body and bed ; and the cachexia of most 
patients in these conditions. The term ecthyma is, however, not 
to be discarded, as it suggests to the mind not merely these com- 
posite etiological factors, but the picture in the skin produced as 
a result. 

The disease is characterized by the occurrence of one or of several 
minute vesicles filled with clear serum, which soon become changed 
to circumscribed, yellowish-gray, reddish or dark-livid, roundish, bean- 
to filbert-sized pustules, which are the result of a distinctly circum- 
scribed inflammatory process, limited to the base of each lesion 
or extending from it at the periphery in a diminishing hyperemia. 
This process is distinguished by the formation at the base of the pus- 
tule of an indurated phlegmon, which is converted into a loss of tissue 
involving in mild cases the superficial, in severe grades the deeper, por- 
tions of the corium. The purulent or sanguinolent contents of the 
lesions dry in dark-colored, thick, rough, adherent crusts, the color 
being somewhat dependent upon the quantity of blood with which 
they are commingled. On removal of this concretion a minute, 
shallow, circular pit is discovered, invading the true skin to various 
depths, and lined with a tenacious, puriform, and often blood-stained 
product. When carefully wiped clean this solution of continuity, 
which really constitutes a minute ulcer, is seen to have a floor reddish 
or grayish in color and indolently granulating. Both superficial and 
deep-seated types of the disease are recognized with a single ulcer or 
exceedingly numerous areas of ulceration resulting. 



252 INFLAMMATIONS. 

The pustules may be acutely or indolently developed, and, when 
multiple, be coincident or successive. They occasion rather a sensa- 
tion of heat, burning, and pain than of itching, the latter being usually 
more distinct when the lesions are healing under their crusts. Their 
formation may be preceded by mild general pyrexia. They occur at 
all ages and in both sexes, usually upon the extremities, and also upon 
every portion of the body. 

The deeper lesions are followed by persistent punctate or larger 
cicatrices. The entire course of the disease occupies about two 
weeks. The subjective phenomena are a sense of heat, burning, 
pain, and soreness. There may be accompanying lymphangitis or 
adenopathy. 

Etiology. — The pyogenic cocci (in particular streptococci) are the 
efficient causes of most of the lesions ; practically the agents capable 
of producing eczema and dermatitis (traumatism, heat, scratching, para- 
sites, etc.) either effectively operate or influence to a morbid degree the 
subjects of other diseases, such as ansemia, asthenia, struma, variola- 
convalescence, and menstrual disorders. Filth and neglect are most 
common aggravations ; in other words, that circumscribed cutaneous 
ulcer will be the angrier and the deeper which occurs in the victim 
of any depressing disease whose skin is scratched with nails begrimed 
with dirt, and is covered with the products of the excretory processes. 
The pus thus produced is in various degrees inoculable and auto- 
inoculable, as is the product of many inflammatory processes of similar 
grade. 

Pathology. — In many cases of ecthyma there has been demonstrated 
a streptococcic infection of the skin, usually with but few chains of 
micro-organisms visible on bacteriological examination. The pustule 
of the disease differs from the pustule of eczema or the pustule of im- 
petigo in the severity of the exudative process by which it is produced, 
and in its limitation to the exact seat of external irritation. By the 
extension of that process to the corium there is an actual loss of some 
of the elements constituting the papillary layer, the result often being 
a cicatrix which contracts as it grows older, and which is, in milder 
cases, finally barely visible as a minute cicatriform punctum. One who 
frequently examines the skin of the entire body with care can usually 
detect the ancient sites of these lesions by their indelible though insig- 
nificant relics. 

According to Unna, the ecthyma-pustule, as distinguished from that 
of impetigo, is less an epidermal abscess than a result of epidermal 
inflammation, fibrinous at the centre and exceedingly oedematous at the 
periphery. The crust contains fibrin and epidermal layers. 

Sabouraud points out that the original streptococcic infection is 
often succeeded by a secondary microbian involvement whereby the 
staphylococci present are enabled to produce the peripheral lesions of 
impetigo, furunculosis, etc. 

Diagnosis. — Ecthyma is liable to be confounded with the other 
pustule-producmg exudative affections, but as the distinction between 
them is largely artificial and based upon the severity of the inflamma- 
tory process, there is small danger in consequence. Kaposi expresses 



CONGLOMERATIVE PUSTULAR PERIFOLLICULITIS. 253 

the truth in his suggestion that there can be but little objection to the 
employment of the term ecthyma when it is desired to characterize pre- 
cisely the pustular grade of any cutaneous inflammation at a given time. 
The pustules of variola are " ecthymaform," and many of those seen 
in syphilis exhibit similar characters ; but the history of the general 
affection should throw light upon the identity of the cutaneous disease. 
In syphilis, moreover, the ulceration at the base of the lesion exhibits 
the pronounced features of the syphilitic ulcer in its secretion, floor, 
edges, base, crust, and career. The crust, in particular, of the flat 
pustular syphiloderm has the rupioid conical appearance which sug- 
gests the shell of the oyster, and the underlying ulcer is larger and 
deeper than in ecthyma. In the furuncle there is usually a central 
core ; in impetigo the pustules are not deep-seated, and there is no 
ulceration at the base; the crust is superficial, yellowish, firmly ad- 
herent, and the lesions are more numerous. 

Treatment. — The general treatment of patients affected with 
ecthyma is a matter of importance. A proper regulation of the food 
and hygienic surroundings is not to be neglected. Tonics are fre- 
quently indispensable, including iron, quinine, and strychnine. The 
destruction of any pediculi and the cleansing of the skin with soap and 
water will often be sufficient to effect a great change. This fact is 
well illustrated in hospital practice, where young patients rapidly im- 
prove after a bath, followed by inunction with vaselin, and a few sub- 
stantial meals of a nutritious character. When the lesions are abun- 
dant the treatment is in general that of pustular eczema. Crusts are to 
be removed after soakings with oil or fat ; and the floors of the former 
pustules, after washing with carbolated water, should be dressed with 
an ointment containing from 10 to 15 grains (0.666-1.) of mercuric 
ammonio-chloride to the ounce (32.) of lard. If the minute basal ulcers 
are sluggish, they may, after careful cleansing, be touched with a small 
swab that has been dipped in a 0.5 per cent, formalin solution or in a 
solution of mercuric chloride in tincture of benzoin, 1 grain (0.066) to 
the ounce (32.). Carbolic or boric acid or iodoform may be employed 
for the same purpose. For the salve mentioned above may be substi- 
tuted one containing 10 grains (0.66) of calomel, or J drachm (2.) of 
bismuth subnitrate to the ounce of salve-basis. 

In every case of the disease it is desirable to inquire whether any 
medicines have been ingested prior to the appearance of the eruption, 
since these may be responsible for the lesions. 

The Prognosis is always favorable. 



CONGLOMERATIVE PUSTULAR PERIFOLLICULITIS. 

Leloir l gave this name to an eruption which he described as appear- 
ing on the backs of the hands and buttocks and occasionally on other 
parts of the body. 

The disease begins by the appearance of a round or oval, somewhat 
elevated, reddened or purplish plaque, with definite outlines. The 

1 Annal. de Derm, et de Sypli., 1884, vol. v., p. 437, with plates. 



254 INFLAMMATIONS. 

plaque may be no larger than a dime, or it may be of the size of a large 
coin or larger, and may be elevated a quarter of an inch above the 
general level of the skin. Its surface is smooth or mammillated and 
is perforated by numerous follicular openings from which pus or dried 
plugs resembling comedones may be expressed. The openings of some 
of the follicles may be covered by unruptured pustules. Later, the 
patch becomes more phlegmonous, fluctuation can be detected, the fol- 
licles are more patulous, and pus in large quantity can be expressed. 
The whole then has much the appearance of a kerion of the scalp or 
of a flat carbuncle. 

There is usually but one such plaque, though there may be two or 
three, rarely more. Subjective sensations are slight, though there is 
usually some itching and burning. There is no systemic disturbance. 
The disease runs a rapid course, requiring about a week in which to 
develop, after which it remains stationary for a week or two, and then 
disappears under appropriate treatment in from ten to fifteen days. 
More or less deep pigmentation remains some time after the lesions 
heal, but there is no ulceration and in the few cases in which scars are 
left they are usually very superficial. 

Folliculitis and Perifolliculitis. — Quinquaud and Pallier 1 
describe a follicular disease which is chronic, becomes papillomatous, 
and is very stubborn under treatment. Besnier and Doyon 2 enumerate, 
in all, five varieties of the disease, including two pseudo-ulcerative, 
serpiginous, and virulent forms which resemble anatomical tubercle. 

Etiology. — These disorders are probably due to contagion, and 
are seen most frequently in those who work among horses and other 
animals. 

Pathology. — The process is an inflammation of the follicles, peri- 
follicular tissues, and sebaceous glands. Leloir found several forms 
of micrococci and zoogloea in the pus, but he failed to reproduce the 
disease by inoculation-experiments. Quinquaud and Pallier believe 
the active agent to be the staphylococcus pyogenes albus, which acci- 
dentally obtains entrance to the follicles and glands. Sabouraud found 
in several cases a large-spored trichophyton. 

Treatment. — The treatment is purely local. In the usual milder 
forms daily evacuation of pus, hot boric-acid fomentations, or frequent 
hot bathing, with antiseptic dressings, constitute the only treatment 
necessary. In stubborn forms stimulating treatment by means of 
strong solutions of silver nitrate or of carbolic acid, or by means of the 
actual cautery, may be indicated. Occasionally it will be necessary to 
remove the growth with a curette. 

1 " Des perifolliculites suppurees agminees en placards." These de Paris, 1889. 

2 Kaposi : Besnier-Doyon, ed. 1892, vol. i., p. 795. 



HERPES SIMPLEX. 255 

HERPES SIMPLEX. 

(Gr. epnetv, to creep.) 

(Fr., Dartre; Ger., Blaschenflechte.) 

The term " herpes " is responsible for much of the confusion which 
has existed with respect to cutaneous diseases. By the ancients it was 
employed, as its etymology suggests, to designate a disease creeping or 
extending gradually over the surface or within the substance of the 
skin. By several more modern authors the term is employed in a 
generic sense in a futile attempt to distinguish a series of so-called 
r herpetic diseases," and even herpetic diatheses from those of a different 
complexion. The significance which attaches to the word in the minds 
of dermatological authors of to-day is exceedingly simple, and is limited 
to the conditions described in the following paragraphs. Herpes zoster, 
though closely related to other types of herpes, is recognized as a dis- 
tinct disease, and in this work is considered separately. 

Symptoms. — The disease is declared by the occurrence of millet- 
seed- to coffee-bean-sized vesicles (single or relatively few in number, 
and in the latter case grouped), which may be preceded or accom- 
panied by a general febrile process, though in many cases there is no 
constitutional disturbance. The vesicles are usually displayed sym- 
metrically, are short-lived, surviving but for a few hours, and are filled 
with a clear serous fluid Avhich may become lactescent. After acci- 
dental or spontaneous rupture there is left a slightly tumid superficial 
excoriation, which is covered frequently by a light crust and at times 
is characterized by circumscribed hyperaemia, slight infiltration, or 
oedema of the base and periphery. The lesions rarely persist for more 
than a few days, and leave no permanent pigmentation or scar, unless 
complicated by pus-infection. The subjective sensations are not usually 
severe ; they include moderate pain, itching, and heat. 

Herpes Facialis, Herpes Febrilis, Herpes Labialis, " Cold-sores." — 
About the lips, the mouth, the cheeks, and the alse of the nose, more 
j rarely upon other portions of the face, lesions occur singly or in groups, 
possessing the characters described above. Their occurrence is usually 
sudden. Their frequency about the lips has suggested one of the titles 
j under which they are most often described by authors. The tongue, 
j the buccal membrane, the palate, and the larynx may participate in the 
I morbid process ; the lesions in such moist situations being represented 
! by isolated or by grouped dark-grayish patches of epithelium that are 
sensitive and exfoliate. The functions of the mouth in articulation and 
mastication are thus rendered painful. Often the lesions coalesce, form- 
ing in an irregular line of elevated epidermis a pea-sized bleb, spread 
! along the vermilion border of the lip and distended with clear serum. 
The burning and itching sensations which accompany the lesions are 
often marked and distressing. In the course of two or three days thin 
|f crusts form, the exfoliation of which terminates the disorder. The dis- 
ease is common in acute pneumonia and in malarial and enteric fevers. 
In these cases, as Kaposi has shown, the occurrence of the eruption by 



256 INFLAMMATIONS. 

no means augurs favorably in every instance, as, nevertheless, a fatal 
result may follow. The connection between labial herpes and rigors 
has long been recognized, though particular attention has been directed 
to this relation by Hutchinson and Symonds. Trophic disturbances, 
traumatism, exposure to solar heat, unusual fatigue, a simple coryza, 
exposure to a draught of cold air, and temporary gastric disorders may 
suffice to induce the disease. There are patients who can produce the 
lesions at will by tickling the lips with a feather, and in some indi- 
viduals there is an exquisite susceptibility to the disease. The dis- 
order is always short-lived though often recurrent, and the superficial 
crusts which terminate the process are never followed by scars. Sym- 
mers, of Aberdeen, successfully cultivated a rod- or thread-shaped 
micro-organism (solid, filamentous, and without septa) obtained from 
the lymph in vesicles of herpes labialis. 

Labial herpes should not be confounded with the symptoms of La 
Perleche, described on another page. The disease to which the last 
name has been given in France is due to a parasite. 

Epidemic Herpetic Fever, which has been observed by Savage 1 and 
others, has prevailed in institutions in which young subjects are con- 
gregated. There are usually rigor, high fever, a coated tongue, adenop- 
athy, and a vesicular rash over the face. 

The Generalized Herpes of French authors has been rarely seen in 
this country. 

Herpes Progenitalis (Herpes Genitalis, Herpes Prjeputialis) is 
characterized by the appearance of one or a group of transitory vesicles, 
in men on the inner face of the prepuce, especially upon its upper limb, 
on the glans, on the balano-preputial sulcus, or in the adjacent integu- 
ment; in women, on the hood of the clitoris, the labia minora, the 
inner face of the labia majora, or adjacent surfaces even as far removed 
as the buttocks. 

The disorder is seen most frequently in young adults and in early 
middle life, its occurrence after the age of fifty being unusual. There 
is commonly a precedent pruritus or a sensation of heat, sometimes 
very considerable pain, followed by the appearance of one or of several 
pinhead-sized vesicles seated upon a tumid and hypersemic base. Within 
the preputial sac the lesions may either rupture at an early moment or 
assume the features above described as presented upon the mucous 
membrane of the mouth. The resulting oedema of the prepuce is often 
displayed in an annular tumefaction encircling the glans, while the labia 
minora perceptibly project from the general vulvar plane. In these 
localities the floors of ruptured vesicles are particularly liable to be 
irritated (coitus, caustic, etc.), and then pus and even blood may be 
exuded with much angrier excoriation and the resulting crusts be of 
darker shade. In the course of a few days even these crusts fall, and 
the disease is at an end. Successive crops of vesicles, however, may 
prolong the disorder for several weeks. Recurrence is common. 

1 Jour. Cutan. and Ven. Dis., 1883, p. 253. 



HERPES SIMPLEX. 257 

Rarely, a first attack of herpes in man results in an extraordinary 
sensitiveness of the balano-preputial membrane that persists for more 
than a year. The patients are often middle-aged men, married, and 
virgin as to venereal antecedents. The membrane becomes tumid, tense, 
slightly glazed, and dark red to dark purple in hue. Upon any undue 
sliding of the prepuce over the glans there occurs a very superficial 
fissure, whence a drop of serum oozes. The membrane becomes so 
sensitive that the passage of the finger over it is resented as though the 
conjunctiva had been touched. Unusual friction by the clothing or the 
use of a stimulating lotion is followed by intense pain and aggravation 
of symptoms, and the price of coitus is several days' rest in bed. 

Naturally, the diagnosis of herpes progenitalis is between chancroid 
and chancre. The latter will be manifested by its induration, its period 
of incubation, and its characteristic inguinal adenopathy. The chan- 
croid, whether in pustular form or as an inoculated abrasion, is ab 
origine ulcerative in tendency, capable of auto-inoculation, and often 
accompanied by sympathetic, inflammatory, or virulent bubo of one side. 
Balanitis, with its puriform secretion and superficial patches of reddened 
epithelium, is readily distinguished from herpes progenitalis by its 
symptoms, though the two disorders frequently coexist. 

The practitioner should never forget that the patient who exhibits a 
herpes of the genital region to-day may have been inoculated at the site 
of the lesion, which to-morrow or later may take on the chancrous 
modification. The rule to be followed, then, is very simple. No 
individual with progenital herpes can be assured of immunity against 
syphilis until the longest period of incubation of the syphilitic chancre 
has elapsed since the date of the last suspected exposure. 

Herpes progenitalis is almost universally the result of naturally or 
unnaturally induced sexual erethism or of congestion of the genitals 
from other causes. Its occurrence in an individual virgin as to such 
antecedents may be due to the causes efficient in the production of her- 
pes facialis. In unusually sensitive persons it may be associated with 
dyspepsia, constipation, and the phenomena of the gouty state. It may 
follow any of the venereal diseases ; or may be induced simply by filth. 
Though relatively rare in chaste women, it is of common occurrence in 
prostitutes. In some women it frequently accompanies menstruation 
(Herpes Mexstrualis). 

Diday and Doyon 1 believe that true herpes of the genital region is 
always of recurrent type, and well marked by its special course, career, 
and consequences. All others of a false type are divided by them into : 
(1) an irritative form, seen in women as the result of vaginal discharges, 
sexual irritation, etc. ; (2) a pseudo-membranous or diphtheroid form, 
also occurring for the most part in women, presenting vesicular and 
even bullous lesions the rupture of which is the signal for pseudo- 
membranous transformation ; and (3) a neuralgic form, which is merely 
zoster of the genital region. 

Pathology. — The eruptive phenomena are due to irritation of the 
nerves either directly or through reflex excitation. There is in many 

1 Les Herpes genitalis. Paris, 1886. 
17 



258 INFLAMMATIONS. 

(probably in all) cases a localized peripheral neuritis of brief duration, 
involving the superficial nerves. According to Unna, there is a coagu- 
lation-necrosis of the upper prickle-layer. The epithelial elements lose 
their capacity for receiving stains, and undergo a fibrinous transforma- 
tion by imbibition of a fibrinogenous material from the surrounding 
media. This coagulated mass is readily loosened from the papillse and 
pushed out by the exudate to form a bleb, the roof of which is thus 
constituted of the necrotic epidermal layer and the walls of deeper layers 
which have undergone the same change. 

Treatment. — The milder forms of herpes occurring about the lips 
and the genitalia require the simplest treatment. Sponging with pure 
water as hot as can comfortably be tolerated is best followed by local 
use of a weak lead-lotion, a simple dusting-powder, or a zinc salve. 
Alcohol applied locally will sometimes abort the disease. Duhring 
recommends highly the following : 

R Zinc, sulphat, ) __ ~._. . -i qqa 

Potass, sulphid. J aa ^j-3j , 1. dd-4 



Alcohol., 3j ; 4 

Aquae dest., 3vij ; 28 

Sig. Shake and apply freely and frequently. 



M. 



Blenler states that a 1 per cent, ointment of cocaine gives prompt relief 
and shortens the course of the disease. About the lips it is well to 
protect the lesions with flexile collodion or isinglass plaster. Occurring 
upon the genital region, the lesions are to be protected by the interposi- 
tion of a pledget of lint, or a bora ted or salicylated dusting-powder. 
As a rule, ointments are unsuited for the moist mucous surface of the 
genitals, the malodorous emanations from most diseases of such parts 
being retained by all grease-containing compounds. Lotions answer 
far better, and they may be made stimulant with alcohol ; astringent 
with tannin, zinc sulphate, or cupric sulphate ; anodyne with opium 
or cocaine ; and antiseptic with formalin, carbolic acid, or corrosive 
sublimate. Prophylaxis by the local use of aromatic wine, or tannin 
and brandy, with a sexual hygiene that will prevent congestion of the 
genitals is a matter of importance. Arsenic is often of value in pre- 
venting recurrences of herpes simplex. 

HERPES ZOSTER. 

(Gr. CooTJip, a girdle ; Lat. cingulum, a girdle. ) 

(Shingles, Zona, Zoster, Ignis Sacer, Hemizona. 
Ger., Feuerguertel.) 

Symptoms. — The eruption in this affection is usually preceded, for 
a period lasting from a few hours to days and even weeks, by hyper- 
esthesia and neuralgic sensations of moderate or of severe intensity. 
These sensations are usually limited to the area of the integument sub- 
sequently or coincidently displaying cutaneous lesions ; but there are 
exceptions to this rule, as the pains are at times experienced elsewhere. 
Often, though limited to the region about to be attacked, the pain 



HERPES ZOSTER. 259 

occurs where it is experienced in other neuralgias, at the points indicated 
by Romberg as corresponding with regions in which cutaneous branches 
are given off by the nerve-trunks. There may be mild constitutional 
disturbance in the form of malaise or febrile symptoms. Adenopathy 
occurs frequently in the neighborhood of the eruption, and may be 
generalized. 

The lesions of zoster are arranged in from two to a dozen or more 
irregularly shaped groups, commonly along the cutaneous distribution 
of a single nerve. These groups are separated by areas of normal 
integument, show little tendency to coalesce, and may be widely scat- 
tered. Aside from the few exceptions which prove the rule, zoster 
occurs but once in the lifetime of an individual, and is limited to one 
side of the body. 

According to Fabre, the essential lesion, always present even when 
vesicles are not seen, is the first macular efflorescence of the disease 
that appears in the form of brilliant or dull-red, poorly defined, erythem- 
atous macules, groups of which appear in the tract supplied by the 
affected nerve. As the patient rarely presents himself for treatment 
until after the appearance of vesicles, the macules usually escape 
observation, either having disappeared or being overlooked. The 
vesicles, which are generally regarded as more characteristic of the 
disease, appear afterward in from a few hours to a day or more, spring 
from the macules or from the normal skin, and are accompanied by a 
sensation of heat. These typically perfect, isolated vesicles vary in 
size from that of a rape-seed to that of a coffee-bean. They appear in 
successive groups of from eight to a dozen or more, which gradually 
increase in size and attain maturity simultaneously in from three to 
seven days. 

The lesions, when fully developed, project well from the widely 
hyperaBmic base from which they spring, are tense from complete dis- 
tention, and have no tendency to spontaneous rupture so firm is their 
roof-wall. Later their early limpid contents become lactescent or puri- 
form in character. When abundant the vesicles may coalesce and form 
irregular patches. Involution is accomplished by desiccation and the 
formation of a yellowish-brown crust, which falls in from seven to ten 
days after the first appearance of the vesicle. New groups appear during 
a period usually of from six to twelve days, at the end of which time 
vesicles may be seen in all stages of development and involution. The 
average duration of the disease is from ten davs to three weeks. Ex- 
ceptionally, a succession of new lesions may prolong the disease for a 
month or more. 

Disappearance of the vesicles and crusts is followed often by pigmen- 
tation, which may persist for weeks or months. Scarring occurs in some 
cases, especially if the vesicles have been ruptured and exposed to pus- 
infection. The scars left by zoster are characteristic. Not only are 
they limited to the original seat of the disease, but they have also a 
peculiar indented look, as if made by a nail-set and hammer. They 
are angular in outline, and do not exhibit the dead- white color of many 
cicatrices. 

The pain or hyperesthesia of zoster varies greatly in intensity and 



260 INFLAMMATIONS. 

in duration. It is usually mild, but may be very severe, especially in 
old people. It disappears commonly with, or soon after, the appear- 
ance of the eruption, but may persist for months or even for years. 

Zoster occurs chiefly in the upper part of the body, and, though 
limited to one side, this limitation is rarely observed exactly at the 
median vertical line, as a few lesions can usually be seen extending 
beyond this boundary. 

Atypical forms of zoster are seen occasionally. The vesicles may 
be typical and few in number, possibly limited to a single group, or 
they may be abortive and transitory. Papules or vesico-papules may 
be the sole lesions. The vesicles may become transformed into pus- 
tules or bullae, or be filled with blood from capillary hemorrhage, 
producing bluish or blackish lesions, known as Zoster Hjemor- 
rhagicus, or " black herpes." In severe cases there may be ulceration 
and gangrenous or deep-seated phlegmonous inflammation. Keloid- 
like scars occur rarely. 

Recurrent zoster 1 is rare, but a number of cases are reported in 
which an individual had two or more attacks either in the same or 
in different regions of the body. In many of the cases reported, how- 
ever, the recurrent lesions were not typical of true zoster. 

Zoster of simultaneous occurrence on two sides of the body may be 
symmetrical or asymmetrical of development. The disease in either 
form is exceedingly rare. In our experience the anomaly is generally 
the result of herpes either in a syphilitic subject or in one under the 
influence of arsenic. T. C. Fox 2 reports a symmetrical case in an 
infant of five months. 

The eruption may occur over the terminal filaments of nerves which 
have no communicating branches, unless, as suggested by Blaschko, 3 
there be an interlacing of fibres in the spinal cord. 

Anomalous nervous symptoms are: persistence of neuralgia after 
involution of the cutaneous lesions; neuralgia of an intense and intol- 
erable severity at any period of the disease; painful anaesthesia of the 
skin; paretic and paralytic phenomena with resulting muscular atrophy; 
and, in zoster of the head, keratitis and iritis, complete destruction of 
the ocular globe, and falling of teeth and hair. 

According to the regions involved the following types of zoster are 
generally recognized : 

Zoster Capillitii depends upon involvement of the second branch 
of the fifth pair of nerves, and its lesions occupy the anterior and pos- 
terior portions of the scalp. 

Zoster Frontalis occurs in the area supplied by the supra-orbital 
nerve, which springs from the first branch of the trigeminus. Its 
lesions extend from the upper eyelid to the vertex, and spread in a 
fan-shaped figure over one-half of the brow, forehead, and scalp. 

Zoster Ophthalmicus may be a severe and dangerous manifesta- 

1 For ^resume of the literature cf. " Kecurrent Zoster," by Joseph Grindon. Jour. 
Cutan. and Gen.-Urin. Dis., May, 1895. 

2 Brit. Jour, of Derm., 1898, p. 252. 
3 Monatsh. fur prakt. Derm., August 15, 1898. 



HERPES ZOSTER. 261 

tion of the disease, being often complicated by agonizing neuralgia, 
formidable involvement of all parts of the eye, even resulting in pan- 
ophthalmia, ulcerative keratitis, pyaemia, meningitis, and death. Typ- 
ical cases of zoster of this region may not, however, exhibit a single 
untoward symptom of the disease. 

Zoster Facialis depends upon involvement of the sensory nerve- 
fibres of the trigeminus distributed to the face, its lesions being dis- 
played over one cheek, the side of the nose, the half of the lip or of 
the chin. The facial and seventh nerves may chiefly be affected. Care 
must be taken in cases of this variety not to confound the disease upon 
the nose with acne or with painful tertiary syphilitic lesions, errors in 
diagnosis that have occurred. When the lower jaw is involved there 
may be severe toothache, dysphagia, and fall of the teeth, Avith great 
resulting deformity. 

Zoster Nuch^e, seu Collaris, occupies the region extending for- 
ward from the cervical vertebrae to the clavicle, or upward toward the 
occipital region and the auricle. 

Zoster Brachialis occupies the region from the last cervical and 
first dorsal vertebrae over the supra-spinous scapular region and the 
contiguous portions of the upper arm. Rarely, even the skin of the 
fingers and that over the first and second ribs are involved. It is a 
common and usually a mild form of the disease, and is characterized 
by a peculiar isolation of the vesicular groups. It occurs also with 
lesions of exclusively brachial distribution. Thomson, of London, re- 
ports brachial zoster with involvement of the right internal cutaneous 
nerve in which two groups of vesicles appeared in the palm of the 
hand. 

Zoster Pectoralis is the most frequent form of the disease, from 
which the common name " shingles " originated. The eruption occurs 
below the first dorsal vertebra, covers the skin of the thorax as far as the 
lumbar vertebrae, and extends from the spinal column behind to the 
sternal region in front. Two, three, or more of the intercostal nerves 
in this region are commonly involved, and the neuralgia resulting has 
frequently been mistaken for the pain of pleurisy. Children more 
often display this form than any other variety of zoster. 

Zoster Abdominalis. — The area here involved extends from the 
lumbar vertebrae to the median line of the abdomen. Zoster abdomi- 
nalis is usually much less pronounced in its features, and the exanthem 
is less abundant, than in the variety of the disease just described. 
When constipation exists defecation may be attended with consider- 
able pain. 

Zoster Femoralis covers the buttocks and sacrum, and extends 
along the thighs, sweeping from behind forward and from above down- 
ward as far as the popliteal space ; in some cases involving the leg and 
foot. The penis, the scrotum, the labia, the vestibulum vaginae, and 
the anus may then exhibit unilaterally arranged vesicles. As this is 
a relatively rare manifestation of the disease, the diagnostician will 
do well to recall the possibilities in every case of an exanthem lim- 
ited to one side of the perineum, supposed to be the seat of genital 
eczema. 



262 INFLAMMA TIONS. 

Etiology. — Herpes zoster occurs in both sexes, and in the young as 
well as in the old, though it is rarely seen in infants. It shows a ten- 
dency to increase in severity with the age of the patient, especially 
after middle-life. It is influenced by the seasons, as cold and damp 
weather serves to increase its frequency in those susceptible to it. 
Frequently there is a history of recent exposure of the involved region 
to a draught of cold air. A large list of other depressing agencies are 
named as effective in the production of zoster. Among them are 
certain poisons (carbon dioxide, belladonna, and atropine), pyaemia, car- 
cinoma, fever, measles, pulmonary inflammations (including phthisis), 
septicaemia, hemorrhages, traumatism, and malaria. It has also fol- 
lowed vaccination, the passage of electrical currents, the extraction of 
teeth, an accidental prick by a thorn, the tapping of hydatids, and 
gunshot wounds of the body. Inasmuch as no one of these causes 
can be cited as certainly effective in all cases, it can merely be said 
that any influence sufficient to induce inflammation of a sensory nerve 
or its ganglion may be followed by the objective signs of the disease. 
Cases are on record in which zoster followed a prolonged course of 
arsenic. Occasionally zoster occurs in epidemics, or coexists with 
other epidemic disorders, such as influenza. The evidences of direct 
contagion in a few instances are very strong. These facts, and the 
rarity with which zoster recurs in the same individual, together with 
the adenopathy which is often present from the beginning of an attack, 
favor the growing belief that zoster is, in some instances at least, an 
infectious disease. 1 

Pathology. — In some cases there is unmistakable evidence of a de- 
scending interstitial neuritis, but the affection may be associated with 
irritative action in any portion of the nervous tract from central 
to peripheral limit. The researches of Barensprung, Rayer, Wagner, 
Charcot, Kaposi, and others have demonstrated with sufficient clearness 
that in zoster there are always, at some point in the corresponding 
nervous tract (cerebral or spinal centres, ganglia, or the nerves them- 
selves), pathological changes. In the majority of cases in which a 
pathological lesion is demonstrated there is found an interstitial neuritis 
of the posterior ganglion or of the posterior spinal root, but neuritis 
and perineuritis of the peripheral nerves, without change in the more 
centrally situated parts of the nervous system, are reported by com- 
petent observers. In a number of cases multiple neuromata have been 
discovered along the affected nerve, the spinal cord and ganglia remain- 
ing normal. In other instances the irritation of the nerve-tract has 
been due to hemorrhage, degeneration, or pressure from tumors, etc. 
Reflex irritation seems to have been an effective cause in a few cases. 

According to Biesiadecki and Haight, the cutaneous lesions originate 
in the deeper portions of the rete, precisely as in other vesicular dis- 
eases. The exudate from the hyperaemic corium, especially its papil- 
lary layer, presses upward into the rete, the epithelia of which are 
thus separated and vertically elongated, the lacunae between them, 

1 Hay presents an excellent argument in favor of the infectiousness of zoster, and 
gives references to literature on the subject in Jour. Cutan. and Gen.-Urin. Dis., 1898, 
p.l. 



HERPES ZOSTER. 



263 



being distended with serum and a few round cells. Often the vesicles 
form about the hair-sacs. As the exudation increases the rete-cells 
are progressively separated, and finally are discovered free in the ex- 
uded fluid, though some, in changed form but still united to each other, 
may be found in the upper part of the vesicle. Except at the margin, 
the mucous and horny layers are separated by the exudation. At first 
many-chambered with delicate easily ruptured partitions, the vesicle 
represents finally a single chamber filled with serum containing rete- 
cells and a few pus-cells, the latter increasing in number as the vesicle 

Fig. 47. 




Longitudinal section of the third spinal ganglion of the right lumbar region from a case of 
lumbo-inguinal zoster : a,a, ganglion (the black spots correspond with pigmented ganglion-cells ; 
the dark lines with engorged vessels) ; b,c,d,e, fatty tissues surrounding the ganglion ; b,b, nerve- 
filament divided longitudinally at the points of entrance and exit ; c.c, nerve-filament divided 
perpendicularly. (After Kaposi.) 

changes its type. Its base at first rests upon the lower portion of the 
mucous layer ; later, upon the corium itself, in which all signs of pa- 
pillae are absent. In the vicinity of the vesicle the papillae and corium 
are infiltrated and the vessels are dilated, but these inflammatory 
changes do not extend far into the corium. The deep location of the 
vesicle, resting as it does upon the papillary layer, accounts for occa- 
sional destruction of the papillae and consequent scarring. 

The vesicle of zoster (and to a less degree that of variola and of 
varicella) is peculiar in that it contains in the deeper portion and along 
the walls epithelial cells which have undergone transformation into 
round or ovoid globular bodies, usually larger than the normal cells, 
which have apparently a limiting membrane or double-contoured wall, 
and contain from two to a dozen or more rounded bodies. These trans- 
formed epithelial cells have been described as protozoa, but their true 
nature has been demonstrated by Unna, Gilchrist, 1 and others. Other 
varied and extraordinary figures are seen. Among them are rings with 
fragmentary edges and swollen centres (the edge representing a homo- 
genized and fibrinously degenerated protoplasm ; the centre a homo- 

1 Johns Hopkins Hosp. Rep., 1896, vol. i. 



264 INFLAMMATIONS. 

genized nucleus). Elsewhere are thin and expanded shells filled with 
epithelial nuclei. Irregularly " ballooning " balls, baskets, tubes, hang- 
ing cords, and other odd forms take the place of the trabecular found in 
other vesicles. Unna names this peculiar change in the epithelial cells 
a "ballooning degeneration," to distinguish it from the reticulating 
forms. 

Diagnosis. — The vesicles of herpes zoster are not rarely confounded 
with those of eczema ; but the distinction between the two is always 
readily established. In eczema there is itching but no neuralgia ; the 
vesicles tend to rupture spontaneously and never persist as they do in 
zoster ; eczematous lesions are also smaller, more acuminate, and rarely 
distinctly limited to the lateral half of the body. Herpes simplex is 
frequently recurrent, herpes zoster almost never ; herpes simplex is 
exceedingly liable to spread around the mucous outlets of the body, 
and on either side of the latter, while zoster reaches such regions only 
after extension from other parts, and is then almost invariably mono- 
lateral. Its lesions are, moreover, never grouped in the concentric 
circles of herpes iris. 

Treatment. — The purpose of local treatment of herpes zoster is to 
protect the vesicles from rupture and infection, and to relieve pain. 
These ends are best accomplished by thickly dusting the lesions with 
an anodyne powder, such as Anderson's powder, containing morphine 
sulphate, 2 grains (0.133) to the ounce (30.) ; lycopodium with powdered 
opium, orthoform and boric acid, or zinc stearate with acetanilid, etc. 
The vesicles may be punctured with an aseptic needle and the contents 
evacuated, but rupture of the lesions should not be permitted. Over 
the entire affected surface should be gently laid a sheet of soft lint or 
of antiseptic cotton, its meshes being also filled with the powder, and a 
bandage, when practicable, smoothly bound over the whole. In the 
milder cases nothing more than this treatment is needed from first to last. 
The glycogelatins furnish a convenient and effective dressing if the con- 
tents of the vesicles be first evacuated and the surface rendered as nearly 
aseptic as possible. In cases in which the lesions have ruptured and 
their bases have undergone erosive or ulcerative changes oleated lime- 
water with zinc oxide, belladonna, and opium or morphine should be 
applied, and be covered with Lister protective. Carbolated and anodyne 
ointments may also be used, especially toward the conclusion of the case. 
Bleuler 1 states that applications of 1 part of cocaine in 50 parts each 
of lanolin and vaselin not only relieve the pain but also shorten the 
duration of the disease. 

Lotions of carbolic acid and glycerin (1 part to 6), or lead-water 
and laudanum, or the " lead-and-opium wash" may be employed. 
Van Harlingen recommends ^ ounce (15.) each of precipitated zinc 
carbonate, powdered zinc oxide, powdered starch, and glycerin, shaken 
up in i pint (240.) of water. 

Duhring speaks well of collodion with morphine, in the strength of 
10 grains (0.66) to the ounce (30.). Kaposi warns against the use 
of diachylon ointment. Generally, it may be said that ointments 
should be the last resort, but those containing from 10 to 20 grains 

1 Neurologisches Centralblatt, November 15, 1899. 



PLATE III. 




Dermatitis Herpetiformis. 



DERMATITIS HERPETIFORMIS. 265 

(0.66-1.33) of the aqueous extract of opium or of belladonna to the 
ounce (30.), or a 5 per cent, cocaine salve, will at times give relief from 
pain. The oleate of cocaine and menthol have been used locally with 
great advantage in meeting the same indication. Alcohol ; or resorcin 
2 parts, alcohol 100 parts ; or 1 per cent, alcoholic solutions of menthol 
or of thymol, may be useful when other measures fail, and it is claimed 
by some that these remedies will abort the disease if used early. A 
continuous galvanic current of between two and three milliamperes 
may be applied over the root of the nerve two or three times daily 
for ten minutes at a sitting. Blistering or dry-cupping, or in sthenic 
cases wet-cupping, may be employed instead of electricity. 

No remedy for internal use is known to have the power of abort- 
ing or of shortening an attack. Quinine is certainly indicated and does 
no harm, but quinine and strychnine in full doses have alike proved 
inefficacious. Other remedies employed are zinc phosphide in -^ grain 
(0.022) doses, repeated every three hours, and, if indicated, in com- 
bination with jr (0.011) grain of the extract of nux vomica; arsenic 
(Kaposi) ; and the tonics in general. Anodynes, by mouth or by hypo- 
dermatic injection, are often indispensable. Inasmuch as many patients 
consider the attack a trivial matter, it is of some consequence that they 
be warned of the possibilities of the future, and that they be confined 
to an apartment of equable temperature in which they are not exposed 
to atmospheric changes. This measure is of special importance in the 
zosters of the face. A skilled oculist should be consulted in cases in- 
volving the eye. 

Prognosis. — Zoster usually runs a benign and self-limited course. 
The prognosis in exceptional cases may be in the highest degree grave. 
Many severe cases have occurred in which patients, after years of 
intense suffering, have resumed the occupations of life, physical wrecks 
of their former selves, their faces indented with scars, and the vision 
of one eye impaired or ruined. Rarely the termination is fatal. 

DERMATITIS HERPETIFORMIS. 

Dermatitis herpetiformis is a malady which, in one form or another 
and under different titles, has long been recognized and described. 
The credit, however, of clearly establishing its identity, and of recog- 
nizing one process as differently expressed in the several observations 
of others, is largely due to Duhring, of Philadelphia. 1 

The identity of the disease as a special pathological process has only 
lately been established. Much investigation is yet required before 
settling definitely many of the interesting questions it presents for con- 
sideration. Duhring regards its vesicular and bullous forms as iden- 

1 " Dermatitis Herpetiformis ; its Relations to So-called Impetigo Herpetiformis." 
Amer. Jour. Med. Sci., October, 1884. " Dermatitis Herpetiformis ; Case of, Caused 
by Nervous Shock," etc. Ibid., January, 1885. "Case of Dermatitis Herpetiformis, 
Illustrating the Pustular Variety of the Disease." Jour. Cutan. and Ven. Dis., vol. i., 
No. 8. " Case of Dermatitis Herpetiformis with Peculiar Gelatinous Lesions." Med. 
News, March 7, 1885. "Notes of a Case of Dermatitis Herpetiformis," etc. N. Y. 
Med. Jour., November, 1884. "A Case of Dermatitis Herpetiformis (Bullosa)." Ibid., 
July, 1884. Cf. Duhring, p. 436. 



266 INFLAMMATIONS. 

tical with "herpes circinatus bullosus" (E. Wilson); "pemphigus 
prurigineux " (Hardy) ; " herpes gestationis " (Milton, Bulkley, and 
others) ; " pemphigus " (Klein) ; " pemphigus circinatus " (Rayer) ; 
" herpes phlyctaenoi'des " (Gibert) ; " pemphigus aigu prurigineux yi 
(Chausit) ; " herpes iris " (Jarish) ; " fatal pemphigus-like dermatitis " 
(Mayer) ; " peculiar skin-eruption " recurring during pregnancy " (Os- 
wald) ; " bullous eruption of a peculiar character " (Leigh) ; " pem- 
phigus compost " (Devergie) ; and " hydroa " (Jones, Bulkley, and 
others). 

Symptoms. — Constitutional symptoms are usually slight or wanting, 
but the first appearance of the disease and the succeeding attacks or 
exacerbations are frequently announced by malaise, sensations of chilli- 
ness, decided rigors, or alternations of cold and hot sensations, with 
systemic disturbances. The skin usually is the seat of pruritic or 
of burning sensations, followed in the course of from twelve hours 
to two days by the appearance of the exanthem, which may be macular, 
papular, tubercular, vesicular, pustular, or bullous in type, or be com- 
binations of these lesions recurring in every variation. The lesions 
may be cutaneous, muco-cutaneous, or mucous in situation. 

The macular form of eruption appears in small-coin to palm-sized 
patches, irregularly rounded, coalescing, well or ill defined as to out- 
line, and slightly raised, suggesting the lesions of erythema multiforme 
or urticaria. Imperfectly defined maculo-papules, papules, and pap- 
ulo-tuberculous lesions, varying in shape, size, and firmness, may also 
spring from or be intermingled with the reddish maculations described 
above. 

In typical development, however, the disease presents cutaneous 
symptoms of herpetic type. Flat, slightly elevated, hard, angular, 
irregularly outlined vesicles may appear, pinhead- to bean-sized, and 
tensely distended. They may be pale yellow or darker in color and 
with or without areolae. When bullae form they may be sparse or be 
plentiful, and be bean- to egg-sized, with cloudy, lactescent, hemor- 
rhagic, or purulent contents. Pustules when present are single or are 
clustered, pinhead- to bean-sized lesions, flat, each surrounded by a 
livid areola. When evolution is complete, segments of rings, or dis- 
tinct rings, of new minute or large pustules surround those first formed, 
and in less than a week these rupture and become covered with a 
crust, which is flat, adherent, and yellowish, greenish, brownish, or 
blackish in color. When there is coalescence a large coin-sized pustule 
and crust may result, and even extensive patches of these coalesced 
lesions may form. The lesions may number from a score or fewer to 
hundreds. 

The imprint of the cutaneous symptoms is multiformity and recur- 
rence. Vesicles, pustules, and bullae without order or regularity of 
evolution or of recurrence appear at one and the same time, in rapid or 
in slow succession, and, without fixed intervals of appearance, for 
months at a time. Generally, however, a prevalence of one special 
type of lesions may be noted during a single period of outbreak or of 
recurrence. This prevalence is in the direction generally of lesions of 
an herpetic type, viz., the vesicular and the bullous in groups, though 



DERMA TTTIS HERPETIFORMIS. 267 

less frequently one of the other types may predominate, and rarely 
vesicles may be absent. 

As a result of the conditions described above a peripheral new for- 
mation of lesions tends to produce marginate patches in which grouping 
occurs, the groups, however, being interspersed with diffusely dissem- 
inated lesions of various types. The irregular, angular, or stellate 
forms of the lesions containing fluid are highly suggestive. Pigmenta- 
tion and infiltration of the skin are commonly noticed. The subjective 
sensations of burning increase and diminish as cutaneous lesions are 
multiplying or are disappearing. The pruritus is in some cases more 
severe than in eczema, and the traumatisms of scratching add greatly 
to the multiform features of the disease. 

The disease lasts for months and even for years. Duhring reports 
cases lasting from five to fifteen years, with periods of relative or of 
entire immunity. In one of Duhring's cases there were thumb-nail- 
sized, raised but flat, golden-yellow-colored lesions, of firm consistency, 
containing a similarly colored, thick, consistent, gelatinous pulp ; these 
features have been noted in several other instances. 

When the oral cavity is invaded there appear upon the sodden and 
macerated mucous surface pustules and bullae, which rupture, leaving 
raw and unhealthy-looking erosions, even sloughing patches of mucous 
membrane. Crusts form about the nares and the lips, and the stench 
from the patient is intolerable. In the same way the vulva, the anus, 
and the prepuce may be surrounded by vesicular and bullous lesions 
which form also on the mucous surfaces adjacent, and pursue a course 
similar to that recognized in the mouth. 

In grave cases, as the skin-symptoms exhibit a marked aggravation 
the systemic condition changes for the worse. After a low fever alter- 
nating with chills and accompanied by progressive cachexia and emaci- 
ation, an intermittent diarrhoea or a pneumonia may close the scene. 
The repulsive appearance of the patient at the last, in severe cases, is 
as formidable as in fatal cases of confluent variola or of severe pityriasis 
rubra. 

Etiology. — The disease occurs at all ages, but much more commonly 
after adult years have been attained : often in individuals of neuras- 
thenic type or in those in whom the nervous system has been subjected 
to unusual strain. Mental crises, nervous shock, fright, anger, physical 
fatigue, and defective renal excretion have all been noted as causes of 
the malady. Among other effective conditions have been named men- 
strual irregularities, pregnancy, the puerperal state, and septicaemia. It 
is possible the irritation of the nervous system may be due in every case 
to a toxaemia, but by many the disease is considered purely a neurosis. 

Pathology. — Our personal knowledge of the pathology of this affec- 
tion is based upon the study of a number of sections of the skin removed 
from the person who was the subject of the sketch from which the 
accompanying plate was prepared. The following is Duhring's account 
of the pathology of the affection, which fully substantiates our own 
conclusions. In the mucous layer are vacuolated cells with shrunken 
nuclei and a few polynuclear leucocvtes. The granular layer is discern- 
ible. The blood-vessels of the papillae are dilated and contain erythro- 



268 INFLAMMATIONS. 

cytes, poly nuclear leucocytes, and eosinophilous cells with fibrin. A 
succeeding stage exhibits infiltration of the papillae with polynuclear 
leucocytes, small mononuclear cells, and eosinophilous cells. In a yet 
more advanced stage the infiltration pushes the epidermis upward, 
leaving a clear space beneath filled with fine fibrinous strands and 
coagulated albumin. Larger and larger vesicles are formed by conflu- 
ence of the swollen cells in adjacent papillae, the vesicles becoming filled 
with a close, fine or coarse, network of fibrin containing in its meshes 
polynuclear leucocytes, epithelial cells, eosinophilous cells, and coagulated 
albumin. Eosinophiles are seen in many cases between the epithelial 
cells. The deeper portion of the corium is for the most part unchanged. 
Eosinophilia is present as a rule, but its exact significance is not estab- 
lished, as it is found in other conditions. Lerrede 1 believes that eosin- 
ophilia when combined with excretion of eosinophiles through the skin 
is peculiar to dermatitis herpetiformis and allied conditions. 2 

The Diagnosis in classical cases is readily made ; in others the dis- 
tinction between dermatitis herpetiformis, impetigo herpetiformis, and 
certain forms of pemphigus is exceedingly difficult. It is possible that 
between the three there may be transitional forms scarcely to be assigned 
to the one category or the other. The same is true of certain excep- 
tional varieties of erythema multiforme. The diagnostic value of the 
presence of eosinophilous cells (the fluid drawn from the blebs having 
been reported by Lerrede and others as equal to from 30 to 95 per cent, 
of the total number of leucocytes) has been weakened by the discovery 
of these same bodies in large numbers in the serum removed from 
simple blisters of the skin. 

The diagnostic features of the disease are : chronicity, with or with- 
out remissions or intermissions ; multiformity of the lesions, among 
which those of herpetic type usually predominate ; the tendency of the 
lesions to appear in groups or patches ; the very marked capriciousness 
and variableness of the recurrences and exacerbations in their times of 
appearing, and in the nature, extent, and severity of the lesions ; itching, 
often intense ; and more or less pigmentation. 

Treatment. — Internal treatment has been directed to meet the indi- 
cations, presented. Of great importance are hygienic measures with a 
view to maintaining the patient's general health. All excesses, excite- 
ment, and everything tending to interfere with the equilibrium of the 
nervous system should be avoided. A nutritious but simple diet, regu- 
lar habits of living, with sufficient outdoor life and exercise, are all of 
great value. Medication is directed chiefly toward improving the tone 
of the nervous system, for which purposes strychnine, quinine, iron, 
small doses of arsenic, and phosphorus may be used. Preparations of 
malt and cod-liver oil are often indicated. Mild laxatives, and the free 
drinking of water between meals and before meals, are of value in 
aiding elimination. For the same purpose small doses of mercurous 
iodide may be continued for weeks at a time. Stelwagon has found 

1 Annal. de Derm, et de Syph., April, 1899. 

2 For a full discussion of the relation of this disease to allied vesicular and bullous 
dermatoses, cf. articles by Jamieson, Brit. Jour, of Derm., 1898, pp. 73 and 118 ; Brocq, 
Annal. de Derm, et de Syph., 1898, pp. 849 and 945 ; and Lerrede, Monatshft. f. prakt. 
Derm., 1898, p. 381. 



POMPHOLYX. 269 

general galvanization of value in one or two patients. In exceptional 
cases arsenic in full doses acts almost as a specific ; it is of most value 
in vesicular and bullous eruptions. It should be remembered that when 
arsenic is not suited to a given case large doses of the drug may do 
much harm. 

Other existing disturbances of the general economy due to rheu- 
matic tendencies, kidney-disease, indigestion, constipation, or other cause 
should be recognized and properly be treated. 

Locally treatment is directed to keeping the surface clean and aseptic, 
and to making the patient comfortable. Duhring recommends stimu- 
lating applications when they are well tolerated, but in many cases 
soothing and sedative preparations are necessary. Among the stimu- 
lating applications which have proved of value may be mentioned 
lotions and oils containing tar, carbolic acid (1 to 20 per cent.), ichthyol 

1 (2 to 10 per cent.), and thymol (1 to 5 grains (0.06-0.33 to 30.) to the 
ounce). Stelwagon highly recommends liquor carbonis detergens in 
strength varying from 1 part to 10 parts of water up to the pure solu- 
tion. Duhring found sulphur ointment (2 drachms of sulphur to the 

| ounce (8. to 30.) ) of great value in cases in which there were vesicular, 
pustular, and bullous lesions. This ointment should be rubbed in vig- 

i orously, but should be tried on a small surface at a time for fear of 
inducing irritation. 

In most cases a soothing treatment is demanded by means of alka- 
line, bran-, or other demulcent baths, followed by some of the dusting- 

I powders or the lotions advised for use in the acute stages of eczema. 
Ointments are not indicated, as a rule, but in a few cases diachylon oint- 

' ment (Hebra), Lassar paste, zinc, mercurial, and other pastes and oint- 

, ments have been used to advantage. For relief from itching camphor 
and chloral (1 to 5 per cent.) in oils or ointments may be employed. 
Many patients are treated with very great comfort to the end in the 
continuous warm water-bath. 

The Prognosis is always doubtful, and is often grave. It is not 
certain that the disease is ever completely relieved, though temporary 
recovery from repeated outbreaks is common. 

Herpes Gestationis (Pemphigus Hystericus) is a name that 
has been employed to designate erythematous, papular, vesicular, and 
bullous lesions, accompanied by marked pruritic and burning sensa- 
tions, occurring usually upon the extremities, but also upon other parts 
of the body. The subjects are usually pregnant or hysterical women, 
who are said to exhibit recurrent attacks in successive conditions of 
pregnancy or neurotic disorders. The view of Duhring, that this dis- 
order should be included under Dermatitis Herpetiformis, should be 
accepted. 

POMPHOLYX. 

(Gr. tto/x^oIv^ a bubble.) 

(Cheiro-pompholyx, Dysidrosis.) 

The disorder indicated by the above title has been the occasion 
of no little medical controversy. Observers are not agreed as to its 



270 INFLAMMATIONS. 

nature and identity. Kaposi asserts that the symptoms are those 
simply of acute eczema. Tilbury Fox, Hutchinson, Robinson, and 
others have made careful studies of the malady. The paragraphs in 
this treatise devoted to dysidrosis are intended to call attention to the 
disease as it occurs in connection with the affections of the sweat- or 
coil-glands. 

Symptoms. — The disease affects simultaneously and, as a rule, sym- 
metrically the hands and the feet ; if either organs are spared, it is com- 
monly the feet. One side may be more extensively involved than the 
other. The eruption is preceded or is accompanied by a burning or a 
tingling pain, and is characterized by the appearance on the dorsum, or 
the sides of the fingers, or over the palms and soles, or over the whole 
hand or foot, of deeply set, single or numerous, grouped or confluent 
vesicles, or of vesico-bullae. According to Fox, in the earliest stages 
of the vesicles annular collections of fluid may be seen about the sweat- 
pores. The appearance of well-developed lesions is compared with that 
of boiled sago-grains imbedded within the skin. When the bullae attain 
extreme development the distended lesions, as large as pigeon's eggs, 
project from the skin, these lesions being irregularly outlined and con- 
taining a neutral or an alkaline fluid, translucent or turbid, and seated 
on an oedematous, often exquisitely painful and sensitive skin. The 
bullae are said not to rupture spontaneously, but to undergo absorption 
in a fortnight or more, with exfoliation of the loosened epidermis ; but 
there are well-marked exceptions to the rule. Beneath the purposely 
ruptured bullae is a new-formed and reddened or exfoliated and sodden 
(which under favorable circumstances becomes later a sound) epidermis. 
There may be coincident malaise, thermal changes, marked mental de- 
spondency, or hebetude. The hyperidrosis mentioned by some authors 
may or may not be a prominent feature in the case of affected patients 
before and during the occurrence of the disease. There may be recur- 
rent attacks in consecutive seasons, and also recrudescence of the dis- 
ease in the affected. It occurs in both sexes, but apparently more often 
in women in England ; in America it is believed that more male pa- 
tients have suffered. The ages of the latter are from those of childhood 
to those of middle life ; one well-marked case occurred in a man of 
sixty. The sufferers, with but few exceptions, are in poor health, are 
broken down from nervous overstrain, and are neurasthenic rather than 
cachectic. Mild types of the disease occur which it is difficult to dis- 
tinguish from pemphigus benignus. 

Pathology. — The differences among observers respecting the char- 
acter of the disease depend upon whether the view is taken with Fox, 
Crocker, and others, that the vesicles lie directly connected with or in 
the line of the sweat-duct ; or whether, with Hutchinson, Robinson, 
and others, no connection with the coil-glands is recognized, the vesi- 
cles lying in the superior portions of the rete over the papillae and not 
over the rete-pegs which pass below to meet the ducts of the coil-glands. 
Crocker, however, found lesions in both situations. The disease ocelli's 
most frequently in persons who are worried or nervously depressed, and 
is probably a neurosis. 

Diagnosis. — Pompholyx is to be differentiated from eczema. The \ 



PSORIASIS. 271 

tendency of the vesicles to persist, and after intentional rupture to fail 
to furnish a serous exudate, is strikingly different from the course of 
eczema. Again, there is seldom, if ever, in well-marked pompholyx a 
tendency to change in type from a serous to a pustular exudation. 
Lastly, eczema of the palms and the soles is almost invariably of ery- 
thematous type. It differs from pemphigus in the absence of cyclical 
phenomena, in its special localization, and in its frequent vesicular 
origin. 

Treatment. — The internal treatment of these cases is of importance. 
Patients require the best climatic and hygienic environment and mental 
distraction. In the way of medicaments, quinine, nux vomica, iron, 
the mineral acids, ergot, cod-liver oil, matzool, and kumyss may be 
needed. The local treatment is by employment of diluted black wash ; 
oleated lime-water with zinc oxide or bismuth subnitrate, or Lassar 
paste covered with boric or salicylated powder ; or by the application 
of strips of muslin spread with lead or with zinc salves. 

The disorder is in certain subjects due to strictly inherited tendencies. 
We have had under observation three typical cases in the person of a 
mother and two children, one of the latter a girl, all of whom had 
suffered since birth from successive crops of vesico-bullous lesions with 
hyperidrosis of the hands and feet. The heart of each was in an irrita- 
ble state, the pulse-rate of the mother having been repeatedly registered 
at 122 to the minute. All three patients complained of gastric crises. 

In France a number of disorders accompanied by coldness and 
sweating of the hands and feet, and characterized by lesions limited to 
these organs, are cited as instances of dysidrosis. Thus, a passive ery- 
thema and areas of congestion of the skin of the organs named, dis- 
] playing non-bullous lesions, are commonly set down in Paris as illus- 
trations of dysidrosis. It is usual in America to limit the titles 
dysidrosis and pompholyx to the affection here described with marked 
J preponderance of vesico-bullous lesions as hand and foot symptoms. 

In all cases the heart should be examined and the condition of the 
circulation carefully determined. Organic and functional cardiac dis- 
ease is responsible for many cases. 

PSORIASIS. 

(Gr. ipopa, the itch.) 

(Lepea, Alphos, Psora. Ger., Schuppenflechte.) 

Symptoms. — In psoriasis the primary lesion is a punctiform macule 
\ of reddish-brown tint, which always at the earliest moment of observa- 
tion is covered with a delicate whitish epidermic scale. When this 
scale is removed, even by gentle scraping, one or more minute droplets 
of blood exude from the points beneath which lie the vascular papillae 
of the corium. 

The lesions of psoriasis vary so widely in size, shape, and distribu- 
tion that the several phases of the disease have been given descriptive 
names. These names have no pathological significance, and are used 
solely for the purpose of indicating the size, configuration, and distri- 



272 INFLAMMATIONS. 

bution of the lesions. When the disease appears in the form of small 
scale-covered points it is called psoriasis punctata. Should the disease 
progress to fuller development, there form patches of larger size, always 
with a definite contour, very slightly elevated above the general level 
of the integument, and covered with whitish, mother-of-pearl-colored 
scales in abundance. When these scales are about the size of drops 
of water the disease is termed psoriasis guttata. In more advanced 
conditions of the disease other names are employed. Thus, psoriasis 
nummularis is characterized by small coin-sized patches ; psoriasis cir- 
cinata or orbicularis, by patches in which the disease is actively exhib- 
ited at the periphery of a circle, in the centre of which the scales have 
disappeared ; psoriasis gyrata and figurata, by coalescence and extension 
of several patches, forming thus fantastic figures covered with grayish- 
white imbricated scales ; and psoriasis diffusa, by much more extended 
and uniform involvement of the skin in large areas. In psoriasis 
follicularis the coil-glands and hair- follicles are chiefly invaded. 

The greatest variation is exhibited in the progress of the disease, 
and to this point special attention should be directed. Thus, in a 
single individual the eruption may appear upon one or more regions of 
the body in the form of the punctate lesions described above, and 
thereafter may regularly progress through the degrees suggested by 
the list of names given, until the surface of the body is completely 
covered from the crown of the head to the soles of the feet. This 
condition is, fortunately, very rare, and, indeed, denied by some ob- 
servers. One rarely sees a case in which a few square inches of sound 
skin cannot be discovered at some point of the body-surface. More 
often the eruption tends to remain stationary where one or another 
of the less extensively developed phases of the disease has been dis- 
played. Thus, the patches may at no time be larger than half an inch 
in diameter, and, though very numerous, may fail for years to extend 
beyond such a limit. They may persist even for a longer period in 
still smaller dimensions, or, what is perhaps more common, may occur 
in guttate forms upon the chest, and in patches as large as the palm 
over the knee or the sacrum. 

The sites of preference of the disease are over the extensor surfaces 
of the extremities, especially about the elbow and the knee, in which 
situation it is decidedly most common. After these locations should 
be named, in order, the scalp, the region of the sacrum (on which often 
the largest patch upon the body can be discovered), the upper surface 
of the chest, the face, the belly, and the genitals, more rarely the 
hands and the feet. 

The disease is essentially chronic in its course, is never contagious, 
and the efflorescence does not usually awaken any subjective sensation. 
Its features are so pronounced in typical cases that its recognition is 
facile, after appreciating the number and distribution of the patches, 
their clean-cut outline, the unaltered integument between the lustrous 
and shining scales, and the red border of the skin which may crop out 
from beneath the squamous thatch above, or be completely hidden by 
the latter. Rarely a single patch betrays the existence of the disorder. 

When the disease is acutely spreading over the skin-surface it has 



PSOBIASIS. 273 

occasionally a different expression, which is often seen in young adults. 
The patches are perhaps as large as a pullet's egg; are dark or lurid 
red over the whole ; are covered with a more uniformly constituted, 
thin, squamous film or sheet of semitransparent delicate membrane 
through which the red glare of the patch beneath is visible. This con- 
dition may also be seen in young persons to whom arsenic has been 
administered for the relief of the disease, with the production of irri- 
tative effects. 

In its indolent moods the color of the patch varies somewhat with 
the hue of the patient's complexion. Blonde women with flaxen hair 
and clear tint of the integument often exhibit singularly waxy-whitish 
patches, decidedly differing in color from those occurring upon the 
muddy and greasy integument of dark-skinned men. The scales, which 
are usually abundant, may adhere with considerable firmness to the 
patch, or, more frequently, may be shed freely from the surface, in 
pronounced cases powdering the clothing of the patient or the sheets 
of the bed upon which he reposes at night. 

There is never at any time in the course of the uncomplicated 
disease the appearance of other lesions or their sequels, such as vesicles, 
pustules, crusts, papules, tubercles, ulcers, or any discharge-feature. 
The eruption is dry from first to last. Exception may only be made 
in the case of patches occurring in situations where motion of the skin 
produces fissure, an accidental and by no means characteristic compli- 
cation. Exception also may be made of certain acute symptoms, espe- 
cially developed in young and tender skins in which considerable red- 
ness, occasionally with an erythematous halo, appears in and about 
individual patches, with the production of itching, heat, burning, pain, 
or other disagreeable sensations and symptoms of scratching. 

The involution of the disease is evident in a gradual cessation of the 
scale-formation and the exhibition of a normal epidermis which pro- 
gressively spreads from the centre or is at once perceptible over the 
I entire surface of the patches. No cicatrization results. 

Upon the scalp plaques of well-defined contour, covered with thick 
i whitish scales, may mat the hairs, but alopecia rarely results. The 
*! dry condition of these scales contrasts with the greasiness of the 
] crusts formed in seborrhoea of the scalp. Often a fillet or band of 
] diseased tissue, one or more inches in width, projects beyond the 
, border-line of the scalp and forehead. When the vertex is bald 
] from physiological loss of hair the patch of psoriasis usually lingers 
4 near the fringe of the hairs left at the sides of the head, projecting 
' thence to the regions of baldness. On the face, as well as over the 
| genitals, the lesions are usually both indistinct and small-sized, being 
1 displayed, as regards the former locality, over the cheeks, chin, and 
nose, avoiding the parts near the mucous orifices. When there is 
much vascular congestion, especially of the passive kind, the patches 
jf assume a violaceous or purplish tint. All forms of lesions are seen 
. upon the trunk, especially over the dorsum and near the sacrum ; the 
patches in well-marked cases encircling the body in ill-defined parallels 
i reaching from the spine forward. The hands, feet, fingers, and toes 
\i are not often involved, and the palms and soles only so rarely invaded 

18 



274 INFLAMMATIONS. 

as to throw doubt upon a diagnosis based upon the existence of the 
disease solely in these regions. In severe cases the nails are second- 
arily attacked, being thickened, eroded in points, irregularly lami- 
nated, rigid, and becoming brittle and yellowish white or dirty whitish 
in color. 

The amount of scaling varies greatly in different persons and in the 
same individual ; sometimes the scales are abundant and thickly heaped 
up over even small areas; sometimes they are sparse over large areas. 
In acute febrile and other intercurrent diseases the disorder may fade 
or disappear. Where the epidermis is thin the scaling is less ; there- 
fore, over flexor surfaces, near the mucous orifices, and on the back of 
the hands, the scaling is less than over extensor surfaces, in regions 
remote from the mucous orifices, and on the palms and soles. The 
scaling is also less in youth than in advanced years. The disease may 
for years be limited to two or three continuously existing patches, or, 
what is far more common, may recur at irregular intervals and under 
varying circumstances. As a rule, psoriasis is worse in winter and in 
cold climates, though patients may demonstrate the reverse of this. 

The scales may display, instead of a lustrous white, a deep yellowish 
shade, and, instead of being imbricated, may form a thin continuous 
sheet of exfoliated epidermis. When the eruption is disappearing the 
scales fall, leaving a pigmented or slightly discolored patch of integu- 
ment. 

As a rule, psoriasis pursues its course with singularly few complica- 
tions. The gravest cases are those in which arsenic has been adminis- 
tered in large doses for relief of the symptoms, when, probably as a 
result of the medication, verrucous growths develop in the psoriatic 
patches, which later become epitheliomatous. 1 At times the eruption 
is the source of excessive annoyance, being the seat of intense pruritic 
and burning sensations of a persistent type. 

There can be no question that intermediate forms between eczema 
and psoriasis occur, in which forms it is difficult to determine whether 
the two disorders coexist or the one has assumed the features of the 
other. In these cases there are itching and infiltration of the skin, 
with vesicular and other lesions foreign to psoriasis, and a catarrhal 
discharge. 

Psoriasis is not known to affect the mucous surfaces. The lesions 
of so-called " psoriasis linguae" are those of "leukoplakia buccalis," 
of "smokers' patches," of syphilitic disease of the mouth, or flat 
epitheliomata. 

Etiology. — The causes of psoriasis are not known. As no external 
or internal factors can be demonstrated to be effective in its production, 
it is safest to conclude that these unrecognized sources of the affection 
are limited to the skin itself. So far as known, the disease is neither 
contagious nor hereditary. It is not limited to either sex, occupation, 
or social condition; it bears no definite relation to syphilis, eczema, 
gout, rheumatism, struma, or dyspepsia ; it appears in feeble and deli- 
cate individuals as in the most superb specimens of manly vigor and 
womanly beauty, and though not occurring in infancy, yet it often first 

1 Cf. J. C, White's paper, Amer. Jour, Med. Sci. ? 1885. 



PSORIASIS. 275 

appears in early life. Kaposi reports a single case in which the erup- 
tion appeared in the eighth month, and Elliot a case of first appearance 
at the eighteenth month of life. Under these circumstances the ques- 
tion arises : Is this affection of the integument, when uncomplicated by 
the symptoms named above, a disease or a deformity? Certainly in 
a very large number of individuals, displaying through life unchanging 
patches in which the characteristic symptoms are the same year after 
year, the ailment would seem more properly to be classed with the 
deformities than with the diseases of the skin. In point of frequency 
the eruption ranks next after eczema. 

No child was ever born psoriatic, yet believers in the possibility of 
j the transmission of the disease by inheritance are numerous, and some 
of them are careful observers. Robinson goes so far as to say that in 
the " majority " of all cases there is an inherited predisposition to the 
disease. Others conclude it to be an inherited or transmitted form of 
syphilis, struma, tuberculosis, rheumatism, or gout. A¥eyl thinks that 
inheritance may possibly be the sole cause. Bazin admits the existence 
of both an herpetic and an arthritic psoriasis. 

Bearing in mind, on the one hand, the relative frequency of psori- 

, asis, and, on the other hand, the strict tests which should be applied 

i in order to prove that a disease is actually transmitted by heredity, we 

find that the doctrine of heredity in psoriasis fails of establishment. 

i It is putting a low estimate on the actual figures to state positively 

I that there must be more than one thousand psoriatic patients in almost 

1 every country, no one of whose ancestors, so far as known, had psoriasis, 

syphilis, or rheumatism. They furnish too large a body of evidence 

to be either ignored or set aside with a word. Thousands of their 

children are living to-day free for years from any evidence of disease ; 

they, too, call for further proof on this point. 

It has long been known that in psoriatic subjects lesions may be 
developed artificially in the lines of mechanical irritation. In this way, 
i figures in the shape of anchors, crosses, hearts, etc., have been pro- 
j duced on the skin of psoriatic patients, one of whom has been inge- 
niously photographed by Fox, of New York. 1 The disease has also 
been attributed to vasomotor neurosis, to fright, to shock, and to 
neuralgias. 

The disorder is rather more common in male than in female patients 
and it appears to be rare in the negro races. According to Greenough's 
statistics, it represents about 21 per cent, of all cases of cutaneous dis- 
ease. It has followed vaccination, scarlet fever, and other diseases. 

Gowers alone reports the artificial production of psoriasis by the 
1 internal administration of sodium biborate. Allusion is made to this 
fact in the chapter on Dermatitis Medicamentosa (q. v.). Further evi- 
dence would be required to prove that these results differed to any 
' appreciable extent from those recognized in any squamous dermatitis 
f produced by an ingested drug. 

In some cases the disorder is due to exclusion of sunlight from those 

portions of the body covered with the clothing and the hair. Certain it 

? is that only in extreme cases is the face attacked at a distance from the 

1 Photographic Illustrations of Cutaneous Diseases. New York. 



276 



INFLAMMA TIONS. 



Fig. 48. 



on- 



line of the hairs upon the brow and bearded region (sides of the nose, 
cheeks, temples). It is likewise true that after exposure of these parts 
to abundant sunlight, not only when patients are intentionally treated 
by such exposures of the nude body to light in hospitals and in private 
practice, but in occupations which necessitate the same, beneficial results 
are often well marked. 

Lassar 1 succeeded in producing a disease of the skin in rabbits by 
rubbing into various portions of their bodies scales, blood, and lymph 

removed from psoriatic patches 
of a male patient. The disease 
thus induced is said to be capable 
of transmission to other animals. 
Campana, Tommasoli, and other 
Italian observers have repeated 
these experiments, with the result 
of reaching the conclusion that 
psoriasis is produced by a parasite 
as yet unrecognized. 

Pathology. — The observa- 
tions of Wertheim, Neumann, 
Auspitz, Kaposi, and Robinson, 
of New York, are substantially 
in accord respecting the general 
character of the changes occur- 
ring in the course of the disease, 
though they differ upon the ques- 
tion whether it depends upon an 
inflammatory or a purely hyper- 
plastic process. Both views are 
probably correct, the disease being 
at times unquestionably the result 
of a circumscribed inflammation, 
at other times being associated 
with a simple overgrowth of the 
elements of the epidermis, and 
again at times with an inflamma- 
tion which the hyperplasia has 
awakened. There is always abun- 
dant development of epithelia in 
the rete, and, in recently formed 
patches, distention of blood- and lymph-vessels in the papillary layer 
of the corium beneath. In older plaques the rete either dips down- 
ward to an unusual extent between the papillae, or the latter push 
upward in the manner of wart-like prolongations. Both hypertrophies 
concur. The corium is thickened later by an increase of its elements 
which may involve its entire width as far as the connective tissue. In 
the older plaques, also, the connective-tissue elements are often sepa- 
rated by a slight serous infiltration. Hyper-pigmentation is also noted. 
The external root-sheath of the hairs in direct connection with the rete 

1 Deutsch. med, Zeitg., 1885, No. 93- 




f- 






Vertical section from an old patch of psoriasis. 
a, hypertrophied horny layer; b, remnants of 
nuclei ; c, stratum lucidum ; d, granular layer ; 
e, hypertrophied rete ; /, dilated vessels and in- 
filtration in corium. (After Leloib and Vidal.) 



PSOBIASIS. 277 

participates in the same process, thus explaining the defluvium capillitii 
of certain cases, and the resulting transient or permanent baldness. The 
sebaceous glands are secondarily involved in the scalp only. 

Munro 1 studied 1500 sections cut from six lesions in the earliest 
period of development. He states that the primary lesion in every 
instance is a collection of from ten to twenty or more leucocytes in the 
horny layer near the surface. Hyperplasia of the horny layer beneath 
the " miliary abscess " follows and pushes the latter toward the surface. 
Other minute abscesses form in the vicinity and are in turn pushed out 
to the surface. The scales of psoriasis are thus formed of a series 
of horny plates, between which are layers of dried fragments of leuco- 
cytes. In this early period no changes can be found in the corium 
or deeper layers of the epidermis. Though the " abscesses " aud 
their location suggest the presence of micro-organisms, none has been 
demonstrated. 

Unna's conclusions respecting the pathology of psoriasis strongly 
suggest that in his view the disease is parasitic in origin, and that the 
morococcus which he has striven to demonstrate as the efficient cause 
of eczema is also here effective. There is no evidence, however, that 
psoriasis has ever been induced artificially by the transference of these 
cocci to sound from morbid skins. He points out that the readily 
induced bleeding from the scraped psoriasis-patch results from the near- 
ness of the head of the papilla to the surface and the thinness of the 
overlying rete ; and shows that the vessels about the patch ascending 
obliquely are usually increased in length and thickness. The enlarge- 
ment of the papillae he believes to be rather a deformity than an increase 
in volume the result in part of a cellular multiplication and in part of a 
not inconsiderable oedema. But little light is thrown on the essential 
character of the psoriatic process by these observers. 

Lang, 2 of Innsbruck, attracted notice by his alleged discovery of 
certain fungous elements in psoriasis that he claims to be the cause of 
the disease. These fungi he finds in the whitish pellicle beneath the 
superficial squamous layer, to which Bulkley had already called atten- 
tion. After stripping the pellicle or a part of it from the surface, and 
subjecting it to the action of a 5 per cent, solution of caustic potash, 
the epithelium appears translucent, and upon and beneath the epithe- 
lium double-contoured and highly refractive spores become visible. 
Lang considers this fungus to be of the lowest species, different from 
any previously recognized upon the skin, and he terms it " epidermo- 
phyton." 

Weyl, who believes that psoriasis is due to " an inherited weakness 
of the nervous centres," has seen Lang's " brood-cells," and he regards 
them as "myelin-like exudations"; but this position is disputed by 
both Wolff 3 and Eklund, 4 who confirm Lang's observations and who 
believe the disease to be of parasitic origin. They explain the artificial 
production of psoriatic patches in the psoriatic skin by supposing 

1 Annal. de Derm, et de Syph., 1898, p. 961, and Brit. Jour, of Derm., 1900, p. 63. 

2 Vierteljahr. f. Derm. u. Syph., 1878. 

3 Ibid., 1884. 

4 Annal. de Derm, et de Syph., 1885. 



278 INFLAMMATIONS. 

spores to have been deposited beneath the skin, and not previously 
awakened to activity in the sites of such experiments. 

Diagnosis o — The recognition of a pronounced case of psoriasis is 
made with ease, and often by those unskilled in cutaneous disease. 
As usual, it is the atypical form of the eruption that awakens doubt. 
Psoriasis is to be distinguished from : 

Eczema. — Eczema and psoriasis differ in a striking- manner with 
respect to their sites of predilection and their extension from such 
sites in progressive cases. Eczema, from the head to the toes, elects 
the anterior surface of the body, the neighborhood of the mucous out- 
lets, the flexor faces of the joints and limbs, the crevices, folds, pockets, 
depressions, and protected angles of the skin. Psoriasis elects the 
posterior surfaces of the body, avoids the vicinity of the mucous out- 
lets, spreads abundantly over the extensor aspect of the joints and 
extremities, and enjoys the regions of pressure and friction, as the 
skin over the patella and the olecranon process of the ulna. Psoriasis, 
covering the vertex and scalp, lingers at the brow, where its scaly 
thatch stretches from side to side close to the line of the hairs, and 
creeps more indistinctly down the face on either side in front of the 
ear, reluctant to spread over the cheeks, nose, and lips. Eczema 
easily escapes from the scalp to the nose, lips, or chin, or lurks in the 
folds of the pinna of the ear. Psoriasis will cover the back and reach 
forward in front by almost symmetrically disposed parallels in the 
direction of the ribs, while eczema sweeps between and beneath the 
breasts or around the nipple. As before stated, the largest patch of 
psoriasis on the body will often be discovered over the sacrum, while 
eczema creeps upward with a diminishing vigor from the anus between 
the clefts of the nates. Psoriasis often spares the hands and the feet, 
which eczema punishes. 

In individual patches eczema will be recognized by its severe itch- 
ing ; by the scratching it excites ; by the history of moisture, dis- 
charge, and crusting ; by its ill-defined outline ; by its asymmetrical 
disposition, except upon the similarly irritated hands and feet ; and by 
the fewer, more yellowish, smaller, and less lustrous scales which char- 
acterize its squamous varieties. 

Favus of the scalp might be mistaken for psoriasis of the same re- 
gion, but the occurrence of sulphur-colored, cup-shaped crusts, the 
existence of the parasite, the lustreless and brittle condition of the 
hairs, and a possible history of contagion will insure identification of 
favus. In psoriasis, too, the hairs are usually firmly attached in their 
follicles, while they are loosened in favus. 

Lichen Ruber Acuminatus, though a much rarer disease than 
psoriasis, must in cases be carefully recognized as distinct from the 
latter. In lichen ruber the lesions are papular, discrete, and are covered 
by a few scales, these being yellowish in color and never lustrous. 
There is generally a constitutional impairment of health, and, when the 
whole epidermis begins to break up in scales, a condition of well- 
marked marasmus. When scratched, the patches of the disease do not 
bleed. Finally, lichen ruber tends to a fatal termination. 

Lichen Planus. — In this disorder the scales are at the outset attached 



PSORIASIS. 279 

to the apices of minute polygonal papules, which are situated on the 
flexor rather than on the extensor aspects of the extremities, on which 
psoriasis is more abundant. The patches in well-marked cases of 
lichen planus have a characteristic crimson-red or a purplish hue 
rarely lacking, and never perfectly seen in psoriasis. The scales, 
further, of lichen planus are of a characteristic silvery whiteness, 
which is never perfectly seen in psoriasis, though imitated by the yel- 
lowish-white or pearl-white hues of the latter. Lichen planus rarely 
appears in oval or roundish patches, but is peculiar among all derma- 
toses in its angular, linear, and even stellate arrangements. 

Lupus Erythematosus. — In any doubtful case in which cicatricial 
tissue is discovered in the site of a patch on which the disease has 
existed the diagnosis is clear, since psoriasis never leaves a scar. 
Lupus prefers the nose, the cheeks, and other parts of the face com- 
monly spared by psoriasis unless the eruption be very abundant else- 
where. The scales of lupus are scanty, firmly adherent, yellowish, and 
attached to the orifices of the ducts of the sebaceous follicles ; those of 
psoriasis are abundant, lustrous, and shed freely from the surface. 
Lupus is never, like psoriasis, a generalized eruption and is always 
much more chronic in course. There is a bluish and violaceous tint 
to the reddish patch of lupus erythematosus, especially when it occurs 
upon the face, while the highly colored patches of psoriasis are rarely 
facial, being more commonly seen on the trunk and extremities, and 
the outcropping disks on the face are the least colored of any on the 
body. 

Pityriasis Rosea. — In this disease the patches are more oval than 
circular and the scales are much finer than those in psoriasis ; pityriasis 
rosea is, moreover, much more rapid in its career and does not recur. 
When the branny scales are removed the surface beneath does not bleed. 
The centre of the patch is usually tawny or salmon-colored. The 
thoracic surface also may be exclusively involved. 

Pityriasis Rubra. — If psoriasis be in any case universal, its dis- 
tinction from pityriasis rubra would be difficult, if not impossible, on 
the basis of our present knowledge. Indeed, any such distinction 
would have but little practical value. A few typical isolated patches 
of a psoriatic character would point to the origin of the disease in any 
doubtful case. 

In Pityriasis Rubra Pilaris the patches, when such are formed, are 
rarely circular. More commonly they are widely diffused, irregularly 
outlined areas covered, not with large scales, but with fine, dry, bran- 
like concretions not freely shed because more or less firmly attached to 
the underlying surface. Over the scalp the exuvium may exhibit a 
moderate degree of greasiness, never the lime-like scales heaped high 
in typical psoriatic patches of this region. The occurrence of pityri- 
asis rubra pilaris with intense brownish tint over the tip of the nose 
and, with pathognomonic symptoms, on the dorsum of the manual 
digital phalanges, and the waxy lustre of some of the patches, are 
important features. In the affection last named there is often a long 
line of demarcation to be recognized, as, for example, along a thigh or 
over a shoulder, defining the limits on the one side of the widely dif- 



280 INFLAMMATIONS. 

fused area of scaliness and on the other of a sound integument. This 
is rare in psoriasis. 

Seborrhoea. — This disease could only be confounded with psoriasis 
of the scalp; but the last-named- affection is, in the vast majority of 
cases, exhibited also in patches upon other portions of the body on 
which seborrhoea is never seen. Seborrhoea of the scalp also occurs in 
usually diffuse forms, the surface beneath the crusts . being rather 
anaemic and pallid in appearance, not bleeding readily, as in psoriasis. 
The crusts, too, in seborrhoea, are distinctly fatty and greasy when 
rolled between the fingers, and have a dirty-yellowish hue, rarely 
recognized in the whitish scales of psoriasis. In psoriasis the hairs are 
not progressively loosened and gradually thinned as in seborrhoea. 
Lastly, seborrhceic crusts may fringe slightly the line of the hairs at 
the brow, but they rarely form a band an inch or more in width, like 
a frontlet covering the upper half of the forehead, a not uncommon 
development in psoriasis. 

Syphilis. — Psoriasis in many cases greatly resembles the squamous 
and papulo-squamous syphilides. The necessity for a clear recognition 
of either disease occurring in suggestive patches is often of the highest 
importance. 

In syphilis the greatest aid will be obtained by a history in both 
sexes, of infection, adenopathy, and mucous patches; and in women 
of abortions, miscarriages, or stillbirths. Psoriasis is a singularly uni- 
form disease; syphilis is decidedly multiform in its manifestations. 
Syphilitic patches are less symmetrical, more elevated at the edge, and 
the scales with which they are covered are fewer, smaller, and dirty 
whitish rather than lustrous in color. Their circular outline is often 
abruptly broken by gaps, with the result of producing semilunar and 
small arc-shaped segments. In syphilis the eruption is less generalized, 
and shares with other syphilodermata the brownish and purplish hues 
of the skin beneath, lacking the vivid redness and pinkish red of many 
non-syphilitic lesions. The scales of many of the syphilides which 
resemble psoriasis partake of the character of crusts, being agglutinated 
by pathological exudations from the patch; they are rarely so exclu- 
sively squamous as in psoriasis. In syphilis the tendency of the patch 
is to exhibit an affected surface somewhat beyond the line of the scales ; 
in psoriasis the scales more frequently reach beyond the border of 
the affected epidermis beneath. The squamous syphiloderm of the 
palms and soles often occurs only in these localities. Psoriasis is 
extremely rare in such situations, and is not limited to these regions 
exclusively. A psoriasiform circlet limited to the region of the mouth, 
nose, or chin will generally prove to be syphilitic. The disease which 
has for a long time persisted in the production of squamous patches can 
generally be demonstrated to be psoriasis, as syphilis changes its type 
in the course of months. 

Tinea Circinata. — In tinea circinata the discovery of the parasite, a 
history of contagion, and the frequent limitation of the disease to a 
single patch (a feature exceedingly rare in psoriasis) will usually suffice 
to establish a diagnosis. In ringworm of the body the scales are bran- 
like, and are more abundantly formed at the margin of the patch 



PSORIASIS. 281 

where the fungus is luxuriant; while in psoriasis the scaliness is 
usually equally pronounced over the entire area of an invaded patch, 
unless the disease is in process of involution. The occasional occur- 
rence of vesicles and vesico-papules at the peripheral border of the 
patch in ringworm is never observed in psoriasis. Ringworm is never 
generalized symmetrically ; and upon the scalp or beard the discovery 
of brittle and broken-off hairs should always suggest examination for 
the parasite. 

Treatment.— Treatment for relief of psoriasis must necessarily be 
limited to removal of its objective features. This treatment may be 
internal, with a view to the indirect action of the drug selected upon 
the skin ; or topical, with a view merely to the reproduction of a sound 
epidermis in the patches of disease. 

Internal Treatment. — Arsenic enjoys the highest rank in the internal 
treatment of psoriasis. What it is capable of accomplishing in other 
cases it can with best effect accomplish here. Whatever failures must 
be charged to its account in the attempt to relieve other cutaneous 
eruptions cannot safely be ignored in psoriasis. Arsenic administered 
internally is assuredly capable of relieving a certain number of cases 
of psoriasis. Given improperly in any case, it may be either powerless 
or manifestly be injurious. In a definite proportion of patients, most 
carefully selected as fit subjects for its therapeutic action, arsenic will 
prove utterly valueless in the most skilled hands. It cannot be demon- 
strated to possess the power to prevent recurrences of psoriasis, yet 
the latter must be recognized as a disease exceedingly liable to recur. 
Unfortunately, the proportion of cases in which arsenic will and in 
which it will not exhibit its happiest effects is not known. 

The following rules for the administration of arsenic are in general 
to be observed : It should be given with or immediately after the in- 
gestion of food, so that it may be commingled with edible substances 
in the stomach. It should be given at first in small doses which are 
to be cautiously increased. The possibility of the production of toxic 
effects should be remembered, and on their appearance the remedy is to 
be given in a smaller dose, and not completely discontinued unless 
such a course be imperative. If its administration be once determined 
upon, the arsenic should not hastily be withdrawn and another remedy 
substituted, but persistence for months should be enforced if no serious 
objection exist, lest the time be wasted which has been already ex- 
pended in the effort to relieve the disease. 

Arsenic is unsuited for all cases of psoriasis occurring with rather 
acute symptoms, such as subjective sensations and unusually vivid 
redness of the patches. It should not be given when the disease is 
in process of evolution, and, therefore, not in psoriasis punctata and 
guttata, unless the lesions have long been limited to patches of the 
sizes to which these names are given. For the same reasons it is often 
objectionable in the psoriasis of the young, for, though the drug is 
usually rather well tolerated in early periods of life, it is, unfortu- 
nately, in the young in whom the disease is also most often encountered 
in its progressive stages. 

The remedial effect of arsenic, when that is obtained, seems to de- 



282 INFLAMMATIONS. 

pend upon the impression it exerts upon the rete, especially that part 
of it which lies in connection with the derma. When the metal is 
injected subcutaneously its first effects, according to Jamieson and 
JNunn, 1 are indicated by the appearance of a faint, narrow band along 
the base of the columnar epithelia immediately next the corium. This 
band is due to a softening of the protoplasm which separates the epi- 
dermal from the dermal elements. Subsequently the remoter epithelia 
are involved, the protoplasmic threads becoming obscure, the charac- 
teristic arrangement of the epithelia becoming less evident, and the 
natural features of the rete distorted, so that it remains attached to the 
derma by tags and by the prolongations which it sends down to the 
cutaneous glands. Jamieson suggests that arsenic stimulates the 
epithelia to exhaustion, the layer which lies next the blood-vessels con- 
taining the metal first appreciating its effects. 

The preparation usually employed is Fowler's solution, the exhibi- 
tion of which should always be begun in doses of from \ minim (0.033) 
to 3 minims (0.20), this amount to be contained in a solution of fixed 
and relatively large dose, such as a teaspoonful of infusion of pepper- 
mint, wine of iron, dilute syrup of gentian or of orange-blossoms, or 
compound tincture of cardamom with water. When only remedial ef- 
fects are obtained, such as diminution of the scaliness, the dose may 
steadily be continued without change for long periods of time, and 
usually with advantage for some time after the symptoms of the disease 
have entirely disappeared. When, without the production of toxic 
effects the eruption seems unaffected by treatment, the arsenic may 
cautiously, and always under the direction of the physician only, be 
pushed until 20 and even 30 drops of Fowler's solution (the latter 
equivalent to \ grain (0.022) of arsenic) are administered at a dose. 

The constitution of the Asiatic pill is given in the chapter on 
General Therapeutics. This pill is less likely to be as well tolerated 
by the stomach as Fowler's solution, but cases are on record in which 
the psoriasis which proved rebellious under the administration of 
liquor arsenicalis, Donovan's solution, and other internal remedies, 
yielded to the solution of arsenious acid in pilular form. Hebra gave 
two thousand Asiatic pills to a single patient before the disease disap- 
peared ; and in no instance were ill-effects produced. 

With regard to the vulgar opinion respecting the arsenic-habit, 
which a long experience with this dosage has been supposed to beget, 
one never encounters such an instance in a psoriatic subject consuming 
arsenic. Patients who for several consecutive years have, without inter- 
ruption, pursued an arsenical course, thus barely succeeding in keeping 
their cutaneous ailment out of sight, will in many cases affirm that, 
apart from any trifling and accidental toxic symptoms and those evi- 
dent in the course of the eruption, they would not be sensible of the 
fact that they had taken the drug. 

With an enlarging experience, one views with greater distrust each 
year the benefits to be derived from arsenic in any untried case of 
psoriasis. The great possibilities of its failure, of the repeated recur- 
rence of the eruption, of the necessity of continuing the medication 

1 "The Histology of Psoriasis," Edinburgh Med. Jour., January, 1879, p. 627. 



PSORIASIS. 283 

for one or two years, and, after that period of time, of witnessing a 
generalized development of the disease to an extent quite equal to that 
exhibited at the outset — all these considerations have weight in the 
mind of an ordinarily prudent man. Yet, in a minority of cases in 
which, under a judiciously directed arsenical course, the eruption slowly 
disappears and fails to recur, the value of the treatment is incontestable. 

Instead of resorting first to the arsenical dose and afterward to 
other measures, the order should be reversed. That case of psoriasis 
which fails to respond to other treatment may finally be subjected to 
the influence of arsenic. He who, having vainly tried other approved 
measures, essays at last the virtues of this medicament, ought to be 
patient while testing his case with it. He should be willing to try it 
fully and fairly, and of all men be least ready to exchange it for a less 
valuable substitute. No reference is here made to the effect of con- 
joined internal medication with arsenic and external treatment by 
topical applications. However desirable it may be in the management 
of any individual case to arrive at the desired end by the speediest 
method, it is evidently needful, in order to assign to arsenic its exact 
therapeutic value, to understand w T hat arsenic can accomplish unaided 
by topical measures. 

Satisfactory results often follow the internal administration of mer- 
curous iodide in ^ grain (0.013) doses after meals. The remedy is 
given, not in cases in which a syphilitic taint is suspected (for psoriasis 
is not a manifestation of syphilis), but as an alterative. It is believed 
to be effective in consequence of its special effect on the liver. In 
some patients it seems to have little value. 

Crocker has lately advised the use of sodium salicylate and salicin 
in all forms of psoriasis, but especially during periods of active devel- 
opment of the disease, when arsenic usually does harm. Haslund 
recommends potassium iodide, increased from the smaller to the largest 
tolerated doses. As many as six hundred grains of the iodide have 
been administered by this method per diem; it is of occasional service. 
The wine of antimony in 5 to 10 minim doses; chrysarobin, ^ grain 
(0.01) rubbed up with sugar of milk, three times daily; potassium bro- 
mide and sodium iodide have also been administered with reported 
success. 

Sodium arseniate in pill-form and ferrous arseniate have been recom- 
mended by Biell. Lipp injected arsenious acid subcutaneously. Rob- 
inson advises liquor potassse, potassium citrate or acetate, or sodium 
bicarbonate in plethoric and rheumatic patients. In the gouty state 
with excess of urates in the urine he advises : 

R Potass, acetat., ^ j ; 30 

Spts. aether, nit., f^ss; 15 

Vin. colchici, f^ij; 8 

Syr. aurantii, f 5jss ; 45 M. 

Sig. A dessertspoonful three times daily in water after meals. 

As to the other remedies employed internally for the relief of the 
malady, a very fair estimate of their value can be made by remember- 
ing that arsenic is superior to them all. Phosphorus, tar, copaiba, can- 
tharides, colchicum, and pilocarpine have at times a feeble transitory 



284 INFLAMMATIONS. 

influence over the patches of the eruption, but their employment will 
disappoint far more often than satisfy. Iron, quinine, cod-liver oil, and 
the salts of the alkalies will meet important indications in the treatment 
of certain classes of patients, but the eruption is often seen in perfectly 
vigorous and otherwise healthy subjects. The treatment of psoriasis 
by the administration of extract of the thyroid gland is practically 
abandoned as fruitless of desirable results. 

After the use of any one of these remedies it is rare to recognize 
any decided effect upon the cutaneous symptoms, even when patients 
in whose case they were indicated improve under their use, though the 
reverse may be true. 

The diet suitable for a patient may in brief be described as that 
which is indicated by his or her general condition. Most authors 
agree upon the value of a greatly restricted diet. Acids, alcohol, and 
fatty substances should be excluded. Meat should sparingly be sup- 
plied; cooked vegetables and fruits may freely be eaten. Coffee, tea, 
and tobacco should in general be interdicted. Passavant, of Frank- 
fort, on the contrary, claims to have cured himself and others by an 
exclusive diet of meat. 

External Treatment. — The influence of climate in inveterate psoriasis 
should never be ignored. Many patients who suffer from repeated re- 
lapses of the disease are worse in winter, and are either better or entirely 
free from the eruption in summer. In mild climates in which the tem- 
perature is uniformly registered at or near a point of maximum comfort 
for the skin this disease is both infrequent and less severe. Given an 
equable climate many patients obtain prompt relief at the seashore, 
while others improve rapidly under the influence of the dry atmosphere 
of higher altitudes. 

The local treatment of psoriasis requires patience, care, and a cer- 
tain degree of skill. Properly conducted, its results are reasonably 
satisfactory in a large majority of cases. The first indication to be 
met is the complete removal of the epidermic scales from the patches, 
which removal is accomplished in various ways. It is preferable 
to secure first their maceration in some fatty substance, such as one 
of the oils, or glycerin, or vaselin, after which the scales may be 
washed off with the aid of soap and water, the patient being given 
a general bath if the eruption be extensive. If it be localized, these 
oily or fatty substances may be spread upon pieces of lint or cotton, 
and thus be retained in contact with the skin by a bandage. The 
scales may also be removed rapidly with a dermal curette, if they 
occur in few patches, or if the patches are to be found in totality 
or in part upon some portion of the body in which the disfigurement 
demands special attention, as upon the forehead and the cheeks. The 
squamous masses are also removable with water alone, as after maceration 
of the skin in a bath, or after a profuse diaphoresis, or even after mod- 
erate exudation of sweat, if evaporation of the latter be prevented by 
covering the affected part with oiled silk or with rubber cloth. Usually 
there is no difficulty in removing these scales, patients often declaring 
that they can themselves cleanse the surface. They ask to be shown 
how to prevent the recurrence of the desquamation. 



PSOBIASIS. 285 

Baths play an important part in the subsequent treatment of the 
disease. They may be employed, as by Hebra, so that the patient 
remains in the water for from four to eight hours in the day ; or be 
medicated by the addition of sulphur, tar, or other substances, so as to 
combine a medicative with a macerative effect. In private practice 
these baths are much less available than in hospitals. When the erup- 
tion is generalized and an excessive macerative effect is desired an 
undershirt and drawers, made of soft rubber cloth, may be worn by the 
patient for several hours of the day. The sweating is often profuse, 
and is debilitating to such an extent that the psoriatic skin will rarely 
tolerate the treatment for an entire day, or even for that part of the 
day in which active labor is performed. By this sweating alone it 
will at times be found possible to secure complete disappearance of the 
patches. 

In other more obstinate cases, or in those in which for any reason 
vigorous treatment is indicated, as upon the scalp and face, sapo viridis 
may be employed with advantage in the soap-and-water treatment. 
The spiritus saponis kalinus, 2 ounces (60.) of the soap to 1 ounce (30.) 
of alcohol, may be briskly rubbed over the patches with the aid of a 
piece of flannel or a sponge, and then immediately be washed off with 
the oil and scales in a surplus of hot water, or be left for a time in 
contact with the part. Hebra and Kaposi employ a species of soap- 
paste, made by rubbing into each patch a small quantity of green soap 
to which a little water is added until the proper consistency is obtained. 
These inunctions are repeated twice daily for six days. The epidermis 
becomes brownish-colored, and in three or four days afterward it exfo- 
liates in lamella3 ; then a general bath cleanses the surface. In the 
French hospitals a somewhat speedier method is pursued. On the 
evening of the first day the patient is anointed with green soap, which 
is retained upon the skin during the night. In the morning he takes 
an alkaline bath, and immediately after is thoroughly anointed with 
lard. This course is repeated on the second and third days, after which 
the patient is usually ready for topical medication of the diseased parts. 

For the more obstinate cases in which exfoliation of the epider- 
mis is not readily induced more energetic measures have been adopted, 
such as the local use of salicylic acid in alcohol, 1 drachm (4.) to 4 ounces 
(120.), caustic acid and alkalies, scrubbing the patches with nail-brushes, 
floor-brushes, etc., and the use of clean white sand. 

Once ready for topical medication, the patches may be subjected to 
the local action of the remedy selected for the relief of the disease. 
Salicylic acid, in paste, ointment, or plaster, in strengths varying from 
2 to 15 per cent., is often effective. For the face, scalp, and hands 
there is no better remedy in the majority of cases than ammoniated 
mercury in 2 to 20 per cent, ointment or paste. This remedy is cleanly 
and usually causes the lesions to disappear ; but it cannot be used over 
large areas without danger of absorption and constitutional symptoms. 

A remedy of great value in the treatment of psoriasis is chrysarobin 
(or chrysophanic acid). This is a crystalline powder of the color of old 
gold, insoluble in water, but is readily dissolved in hot alcohol, acetic 
acid, benzol, vaselin, and hot fat. It is derived from the " Goa powder " 



286 INFLAMMATIONS. 

of the East Indies, or the " araroba powder " of Brazil, the employment 
of which in psoriasis was first recommended in 1878 by Squire, of Lon- 
don. The drug may be applied in strengths varying from 10 to 40 
grains (0.66 to 2.66) to the ounce (30.) of ointment, paste, plaster, col- 
lodion, or liquid gutta-percha. It is occasionally used in lesser and 
greater strength, but with pure specimens it is liable in larger propor- 
tions to produce disagreeable effects. These effects are -declared in a 
hot, itching, swollen, irritable, and erythematous or darkly stained skin, 
stretching with tolerable uniformity in every direction from the surface 
of application. Even in the strength named above it is necessary to 
begin its use with caution, testing it by application first to a limited area 
of integument. These excessive effects usually subside in a few days. 

When the drug produces its most brilliant effects the psoriatic patch, 
previously denuded of its scales, assumes a whitish and normal aspect, 
contrasting thus somewhat remarkably with the chocolate or brownish- 
black discoloration of the stained skin at the periphery. This discolora- 
tion, when produced either by the ointment directly or by a frequent 
transfer of its ingredients to other parts by the medium of the clothing 
and the hands, involves also the nails, the hairs, and the underlinen of 
the psoriatic patient. Its employment upon the face and the scalp is 
thus largely interdicted. The staining of the skin and its appendages 
disappears entirely in time, but always slowly. 

Fox, 1 of New York, employs a soft paste, made by rubbing chry- 
sarobin with a sufficient quantity of water, which is smeared upon the 
psoriatic patches, the scales of which have previously been removed 
by one or more hot baths, with soap friction. As soon as the paste 
has dried, which it does in one or two minutes, a layer of collodion 
is allowed to flow over each patch, and to harden into a protective 
coating. This coating will remain in place for several days or longer, 
according to the location of the patches ; when it falls or is washed off, 
the application of the powder and the collodion should be repeated. 
By this procedure the chrysarobin in full strength is kept in contact 
with the affected skin, and is prevented from exciting undue inflamma- 
tion of surrounding parts or from staining the clothing. A mixture 
of the powder and the collodion may be used, but it is less efficacious. 
A film of collodion doubtless interferes with the action of the acid 
upon the skin. A somewhat similar plan consists in the use of gutta- 
percha tissue to retain a strong chrysarobin ointment in contact with 
psoriatic patches. The edges of this tissue will adhere tightly to the 
skin if a small camePs-hair brush, dipped in chloroform, be passed 
rapidly beneath them. Following Auspitz's plan, Fox has added 10 
parts of chrysarobin and 10 of salicylic acid to 15 of sulphuric ether 
and 100 of flexile collodion. This mixture rapidly dries over the 
psoriatic patch, on which its specific effects are produced. 

Tar is among the most valuable remedies in the local treatment of 
psoriasis. It will, however, accomplish the result desired only when so 
applied that it is well tolerated by the skin. In very young patients, as 
also in those whose skins are tender and irritable, or those suffering 
from any of the acute phases of the disease, it may prove decidedly 

1 Med. News, March 18, 1882, p. 289. 



PSORIASIS. 287 

injurious. The rule should be always to employ it at first tentatively 
over a relatively small portion of the affected surface, upon which the 
medicament should remain for several hours, as tar will not in all cases 
promptly produce its injurious effects. These effects are, subjectively, 
a sense of heat and pain; and, objectively, heat to the touch, redness, 
and tumefaction. Often black puncta are visible when the tar is lodged 
in the orifices of the cutaneous follicles, simulating thus the " black 
head" of the comedo, a condition termed by Hebra "tar-acne." 

Pix liquida, oil of cade, or preferably oleum rusci may be employed 
in the form of a salve, 1 drachm (4.) of either to the ounce (30.) of 
lard or other fatty basis (lanolin, vaselin, etc.). A thin stratum of this 
ointment several times in the day or merely at night may be painted 
over or well rubbed into a patch denuded of scales. In Vienna a still 
more energetic effect is secured by using soft soap freely over the 
patches while the patient is in the bath, then anointing him with tar, 
and finally returning him to the bath, in which he remains for from 
four to six hours. For localized eruptions, green soap in combination 
with tar and alcohol serves a useful purpose, either in the proportion 
of equal parts of the three ingredients, or by combining them in other 
proportions, as, for example : 

B Saponis viridis, ^iv ; 120 



01. rusci, ) __ _. 

Glycerin, J aa ^ ' 30 

01. rosmarin., 3jss ; 6 

Spts. vin. rectif, Oss ; 240 
Sig. For external use. 



M. 



Other combinations of service are the " liquor picis alkalinus," the 
formula for which is given in the chapter on Eczema ; or Wilkinson's 
salve, as modified by Hebra, the latter combining the remedial effects 
of sulphur, tar, and soap, as follows : 



R 


Sulphur, sublimat, 

01. rusci [crud. vel. rectif.], j 


aa §ss; 


15 




Saponis viridis, ) 
Adipis, j 


aa Sj ; 


30 




Cret. prseparat., 


Bijss ; 


3 


Sig. 


Wilkinson's salve, modified. 







5 M. 



Where the sensitiveness of the skin to the action of tar has not 
been tested, or when the skin is particularly tender, a small quantity 
of the Wilkinson salve may be added to any simple ointment, or Spen- 
der's ointment of tar (see the chapter on General Therapeutics) may 
be substituted ; afterward 1 drachm (4.) of the oil of tar, or of oleum 
rusci, to the ounce (30.) of oil of almonds or of alcohol, may be 
employed. 

j When toleration is established the tar may be rubbed over the 

patches in a pure state with a stiff brush, a procedure preferred in 

some parts of Germany, after which the patient either remains for 

'some hours in bed, or is powdered with soapstone and bandaged with 

jflannel, so that when the clothing is replaced it may not adhere to the 



288 INFLAMMATIONS. 

tar. Naphtalin, ichthyol, and carbolic acid operate in psoriasis in the 
same way as the tars, but are decidedly inferior to tar. 

Absorption of any tarry compound applied externally may result in 
general toxic symptoms, including fever, vomiting, diarrhoea, stran- 
gury, the elimination of the toxic agent in secretions which are 
blackened by its presence. These symptoms are usually relieved in 
from twenty-four to forty-eight hours after discontinuance of the 
drug. 

Pyrogallol, first suggested as a remedy for psoriasis by Jarisch, is 
inferior to chrysarobin. The fact that several deaths have been reported 
as consequent upon the use of this acid deters many from making trial 
of it in a painless and merely disfiguring disease. It is used in a 10 
per cent, vaselin ointment, is effective though less rapid in effect than 
chrysarobin, is cheaper, is odorless and painless, and it discolors to a 
less extent the sound skin. Both remedies are capable of being 
absorbed from the skin-surface, and of producing constitutional symp- 
toms (pyrexia, strangury, and blackish evacuations) ; but in the case 
of pyrogallic acid only have fatal results followed. 

Kaposi l was the first to employ beta-naphtol (the formula being 
C 10 H 8 O) in psoriasis, as also in eczema. It may be applied in alcoholic 
solution. Following the employment of a 15 per cent, ointment the 
author reported speedy disappearance of psoriatic patches. It did not 
stain the skin, hair, or nails. 

Crocker, of London, similarly uses thymol in ointment, \ scruple to 
\ drachm (0.66-2.) to the ounce (30.) ; and Williamson advises tur- 
pentine, 2 drachms (8.) to the ounce (30.) of olive-oil, with the odor 
corrected by the oil of lemon. 

The nitrate, as well as the iodides and oxides, of mercury is applied 
by many practitioners in the form of ointment to patches of psoriasis 
usually few in number and limited in extent. The action of these 
agents, however, is inferior to that of those already named ; and the 
range of their availability being limited, they should be esteemed lightly 
in the topical treatment of the disease. Other articles more recently 
vaunted in the external treatment of psoriasis are : thilanin, which 
seems to possess some value ; hydracetin ; cacodylic acid ; rufigallic 
acid, 10 per cent, in unguent form ; cupric oleate ; anthrarobin ; and 
gallacetophenol, 5 to 10 per cent, in salve or in traumaticin. 

When practicable, the skin affected with psoriasis should be exposed 
to the direct action of sunlight in a sufficiently warmed apartment. By 
this measure alone the skin is often relieved of its eruption. 

Prognosis. — The permanent relief of psoriasis is not insured by any 
treatment of a grave case, though hundreds of patients are. permanently 
relieved by even the simplest treatment. The disease often recurs, and 
may do so repeatedly for the greater part of a lifetime. Permanent 
relief, therefore, should never be either predicted or promised in any 
case. Once relieved, it should be the aim of the practitioner to guard 
against all possible recurrences. After relief of any obstinate or re- 
current attack, as also in all inveterate cases, the prognosis is greatly 
improved by removal to a climate suitable for the psoriatic patient. 

1 Wien. med. Woch., May 28, June 4 and 11, 1881. 



PLATE IV. 




Pityriasis Rosea. 



PITYRIASIS ROSEA. 289 



PITYRIASIS ROSEA. 

(Pityriasis Maculata et Circinata, Herpes Tonsurans Macu- 
losus, Pityriasis Circtnata. Fr., Pityriasis rose de 
Gibert, Pityriasis circine et margin^.) 

This disorder has been recognized and described by Gilbert, Bazin, 
Horand, and Duhring. It is non-contagious and benign in its course, 
lasting from a few weeks to three months. 

Symptoms. — The subjects are commonly young adults, but the 
disease is seen in children and in middle life in both sexes. The out- 
break of the malady may be preceded for a variable time by languor, 
lassitude, inappetence, or a feeling of chilliness. Occasionally the first 
noticeable symptom is the occurrence of mild fever, the body-tempera- 
ture rarely rising above 102° F. 

The eruption often escapes recognition for a time after its appear- 
ance on account of its sparseness or the trifling degree of pruritus it 
arouses. When fully developed it is characterized by the conspicuous 
appearance over large surfaces of the trunk, especially upon the integu- 
ment covering the clavicles, the ribs, and the scapulae, rarely on the 
exposed face and hands, of numerous pinhead- to small-coin-sized, cir- 
cumscribed, roundish or oval-shaped, slightly elevated, macular or 
maculo-papular lesions. These lesions may be discrete, closely set 
together, or confluent, and instead of being elevated may be either on 
a level with the general surface or slightly depressed, with an annular 
border. They are dry, covered with furfuraceous rather adherent 
scales, and vary in color from a yellow or tawny shade to a deep red. 
The infiltration is slight, and the patch is superficially situated. 

The fully formed disks vary in long diameter from the width of a 
finger-nail to three or four centimetres. The oval contour is that 
more often recognized as characteristic of a well-developed lesion, the 
long axis of the disk usually corresponding with the lines of cleavage, 
and the terminal extremities of the oval slightly frayed by the irregu- 
larity with which the fine branny scales are there disposed. A tawny, 
salmon-shade is highly characteristic of the disease, the patch slightly 
enlarging by peripheral extension, and leaving a relatively clear centre. 
The scales have often a silvery grayish color. The eruption may be 
tolerably well generalized, but the face and other exposed parts of the 
body usually escape, though the scalp may be involved. In the latter 
event the hairs are unaffected. 

The variations exhibited by the exanthem in this affection are dis- 
tinct, but are scarcely ever sufficient to mask the characteristic appear- 
ance of the oval or circular plaques over the neck, the arms, the ab- 
domen, or the extremities, sometimes first appearing over the latter 
and extending thence to the trunk. At times a retiform expression is 
given to the picture by coalescence of the patches. There may be 
moderate itching with nocturnal exacerbation, but the usual type of 
the disease is mild. Complete involution is usually reached in the 

1 course of a week or a fortnight. 
Etiology. — The causes of this disease are obscure. According to 
19 



290 INFLAMMATIONS. 

Bazin, it occurs chiefly in lymphatic and scrofulous patients. Most 
cases occur in patients having light hair and delicate skins, who have 
been enfeebled by great physical fatigue or by overtaxation in school. 
Profuse perspiration has been assigned as a cause by Horand. Epi- 
demics of the disease have been reported. It is possible the disorder 
is feebly infectious and allied to the exanthemata. 

Pathology. — The histopathology of the disease has been studied by 
Unna and by Hollmann. 1 The changes begin apparently in the papil- 
lary body and the subpapillary layer of the cutis, and include a dilata- 
tion of the vessels, perivascular cell-infiltration, and oedema. As the 
disorder progresses these changes are more marked, especially the peri- 
vascular cell-infiltrate. The rete shows decided intracellular and inter- 
cellular oedema and proliferation of the prickle-cells, especially in the 
interpapillary portions. As the disease approaches its acme minute ves- 
icles, not visible on macroscopic examination, form beneath the horny 
layer, which later is exfoliated. 

Diagnosis. — The disease is to be differentiated from ringworm of 
the body by the absence of vesicles, the tendency to symmetrical dis- 
tribution of the lesions, their multiplicity, the characteristic yellowish 
centre of the oval rather than circular patch, and the constitutional 
symptoms. Psoriasis differs greatly in the color, quantity, and char- 
acter of the scales present, and in the contour of the patch. In the 
scaling syphilodermata, the region of the body involved, the presence 
of plantar and palmar lesions, the constitutional symptoms and history, 
and the color of the patch, which is usually of a deeper and dirtier red 
than in the disease under consideration, will point to the diagnosis. 
In the macular syphiloderm (" syphilitic roseola") the closer proximity 
of the lesions will point at once to the difference, since the patches of 
pityriasis rosea are, as a rule, far more widely separated. The greasi- 
ness of seborrheic scales and the pallid hue of the integument beneath 
when the former are removed differ from the congested skin beneath 
the dry scale in this form of pityriasis. 

The Treatment is expectant. Quinine, sodic salicylate, and, later, 
ferruginous tonics are indicated in most cases. Locally, tepid bathing 
in an alkaline or bran-bath is usually grateful. This bath is to be fol- 
lowed by the application of a dusting-powder. 

DERMATITIS EXFOLIATIVA. 

Some confusion, both as to the names of diseases and as to the dis- 
eases themselves, has existed in connection with the subject of all gen- 
eralized exfoliative cutaneous disorders. More investigation is needed 
before definite limits can be established for several of the dermatoses 
of this class. By some, the term "dermatitis exfoliativa" is held to 
be synonymous with pityriasis rubra. In these pages pityriasis rubra 
is distinguished as a distinct disease, and dermatitis exfoliativa is made 
to include the exfoliative and exudative disorders of the skin not prop- 
erly considered in any other connection. 

Classing these forms of exfoliative dermatitis together as for the 

1 Arch. f. Derm. u. Syph., 1900, Band li., Heft 2. 



DERMATITIS EXFOLIATIVA. 291 

most part of acute type, and distinguishing the chronic forms from 
the pityriasis rubra of Hebra, it may be said of them all that they 
present features of wide diversity. At one time exfoliative dermatitis 
begins and ends in a single patient as a well-defined, distinct, and 
specific disease with mild symptoms, pursuing a definite career, and of 
benign type ; in another case it occurs as a sudden or a gradual change 
in a preexisting disorder, such as an eczema or a psoriasis (Gamberini) ; 
again, beginning in one or another of the simpler forms described above, 
it may become chronic, and in its symptoms and appearance be indis- 
tinguishable from pityriasis rubra. 

Symptoms. — Exfoliative dermatitis is usually ushered in with mild 
febrile symptoms, which are often preceded by malaise, languor, or a 
variable period in which the general health has been impaired. Often, 
however, all prodromata are absent. 

The eruptive symptoms are a more or less shining and vivid redness 
of the skin in one or several plaques which become in the course of 
a Aveek the seat of numerous fine bran-like scales. Any region of the 
body may be affected, though the articular folds of the skin, the genital 
region, the head, and the trunk are most often the seat of the disease, 
which may involve consecutively one part after another until in a week 
or a fortnight the whole body-surface is invaded. The affection may 
be limited to one region, or several distinct regions may simultaneously 
be involved, as the head and the lower limbs, or the thorax and the 
external genitals. The hands and the feet are usually the last to be 
invaded. The eruption may appear in reddish patches of well-defined 
or of very indeterminate outline. The skin affected may be slightly or 
apparently not at all infiltrated and raised. The itching may be slight 
or be severe. The redness displayed in the regions affected with 
scaling may be of the brightest crimson, "erysipelatous," violaceous, 
or purplish shade, or with a faint suggestion of yellowness. The 
scales, which are usually formed in abundance, are commonly seen 
loosely covering the reddish integument upon which they rest, though 
they are also shed in profusion when the affected surface is lightly 
swept Avith the hand. They are always whitish, minute, and bran- 
like, neA T er in the so-called " pastry-crust" condition of the scales in 
pemphigus foliaceus. 

In Avell-marked cases the features may be slightly disfigured by 
tumefaction of the lips, sAvelling of the ears, and puffiness of the eye- 
dids. In all cases the skin is dry and is rarely moistened with a path- 
ological discharge. The scales are always AAmite, imbricated, and 
i silvery in hue ; they are usually larger and coarser upon the lower 
J limbs than 0A T er the neck, face, and chest. 

In the course of the disorder the hairs may fall, and in some cases 
Bbe resulting alopecia is general. When the nails also are lost there 
jis rarely any special preexisting onychia. The mucous surfaces of the 
eyes, nose, mouth, and throat may participate in the general disorder 
and become the seat of inflammatory and, in rare cases, even of pseudo- 
membranous and exulceratiA T e processes. 

Itching may be absent; when present and severe it is relieA T ed eA r en 
before the complete restoration of the integrity of the skin. The itch- 

/ 



292 INFLAMMATIONS. 

ing may recur with each relapse, at which time also the fever is usually 
relighted. 

In most cases the disease is terminated in the course of two or three 
months, after which convalescence from the emaciation and possible 
complications (furunculosis, abscesses, etc.) may require an equal length 
of time. Pigmentation is always present for some time after recovery. 

Etiology. — The cause of the disease is not known. It is often 
accompanied or preceded by an acute or chronic toxaemia. Chronic 
forms of exfoliative dermatitis may follow extensive cases of psoriasis, 
lichen planus, or pityriasis rubra pilaris. 

Pathology. — Brocq 1 has made a study of this disorder, and his 
results are in part confirmed by Viclal and Baxter. These observers 
recognized an infiltration of the papillary layer of the corium with em- 
bryonic cells, dilatation of the papillary and subpapillary vessels, hori- 
zontal flattening of the prickle-cells, disappearance of the stratum 
granulosum and stratum lucidum of the epidermis, and the appearance 
of nuclei in the cells of the stratum corneum. According to Quinquaud, 2 
a diffuse myelitis and parenchymatous neuritis of cutaneous nerves may 
be responsible for these changes. 

Diagnosis. — Exfoliative dermatitis is to be distinguished from pity- 
riasis rubra by the variety of its symptoms and course ; from pemphigus 
foliaceus by the absence of bullae and grave systemic trouble ; and from 
scarlet fever by the absence of sore-throat and by a much more tardy evo- 
lution. Though in general a disease having a cyclical career and special 
characteristics it may at times be lighted into activity by a diffuse psor- 
iasis of acute type, or by a squamous eczema becoming generalized. In 
such cases the diagnosis is qualified by the preexisting disorder. 

Treatment. — The disease may be mitigated by any medicament 
which induces profuse sweating ; hence, both jaborandi and pilocarpine 
have been employed with success. Quinine, soclic salicylate, cod-liver 
oil, and the mineral acids are often indicated. The strength of the 
sufferer is always to be supported by appropriate measures. Hebra's 
diachylon ointment, 1 part to 4 of vaselin, with from 5 to 10 grains 
(0.33-0.66) of salicylic acid to the ounce (30.) of the whole, is usually 
grateful to the skin. One of the combinations of lime-water, olive-oil, 
and zinc oxide, described in the treatment of eczema, may, however, i 
be employed locally. 

Prognosis. — The disorder may prove fatal in exceptional cases ; 
generally, however, recovery may be expected. Often convalescence 
is tedious, protracted, and complicated by the occurrence of furuncles 
and cutaneous abscesses. 

DERMATITIS EXFOLIATIVA INFANTUM. 

(Keratolysis Neonatorum.) 

Under this title Von Bittershain 3 and others have described an 
exfoliating non-contagious disease of the skin in infants from six days 

1 Arch. gen. de Med., 1884. 

2 Bull, de la Soc. anat., 1879. 

3 Centralzeitg. f. Kinderheilk., 1878, Bd. ii. Dorland: Phila. Polyclinic, Sept. ] 
26, 1896. 



PITYRIASIS RUBRA. 293 

to five weeks old, the disorder continuing from seven to ten days. It 
develops as an erythema, at times as a vesico-bullous dermatosis, with 
dryness of the skin, from which branny scales are abundantly exfoliated, 
leaving a peculiarly dry, reddish, and fissured integument beneath. The 
angles of the mouth and the mucous outlets generally are specially in- 
volved. Often buccal lesions are present. The face, the buttocks, and 
the limbs are chief seats of the disease. The malady lasts for about 
one week and is unaccompanied by fever ; it occurs more often in boys 
than in girls. In severe cases crusts form where rhagades exist, and 
there are considerable pain and constitutional disturbance. Occasion- 
ally the skin is attacked by furunculosis after the disease has existed 
for a week. Relapses are common, but recovery occurs in most cases. 

The Treatment is by soothing applications to the cutaneous surface. 

Prognosis. — The mortality is grave when the disorder induces 
marasmus, diarrhoea, or pneumonia. 

PITYRIASIS RUBRA. 

(Gr. Tvirvpov, bran. ) 

(Dermatitis Exfoliativa. Ger., Rothkleie; Fr. y Pityriasis 

RUBRA AIGU.) 

J Symptoms. — This disease is characterized by a superficial hyperemia 
( and inflammation of the skin, declared in patches or by a diffuse red- 
\ ness of a vivid or lurid tint, and by an abundance of small or large, 
( lamellated, bran-like scales, which are continuously exfoliated from the 
epidermis throughout the course of the malady. Patients rarely present 
themselves for observation until a considerable portion of the body- 
surface is involved ; but Kaposi states that in two patients observed 
i| by him the disease was first noticed in the neighborhood of the articu- 
5j lations. There are never at any time other lesions of the skin, betrayed 
in vesiculation, pustulation, moisture, or crusting. The palmar and 
\ plantar surfaces are usually less distinctly reddened than the face and 
t the extremities, having at times even a pallid hue, but they are always 
covered with a scaling epidermis. 

Under pressure with the finger the redness subsides or assumes a 
yellowish shade, while, as a rule, when the integument is gathered up 
between the finger and thumb, no infiltration can be recognized. Ex- 
ceptions, however, have been noticed by several observers. 1 The tem- 
perature of the skin is slightly increased. The exfoliation, as the dis- 
ease progresses, is one of its most striking characteristics, the scales 
accumulating in large quantities in the clothing of the patient, who is 
engaged, as a French writer has it, in the labor of stripping himself 
involuntarily of his epidermis. 

The disease persists for months or for years, being always more 
severe in expression as it advances, the papery scales being shed more 
abundantly and in larger flakes, leaving a smooth, shining, occasionally 
purplish or even cyanotic skin. In the patients observed by Jamie- 

1 We have reported one such case. Cf. " Pityriasis Rubra," Chicago Med. Jour, 
and Exam., Feb., 1881. 



294 INFLAMMATIONS. 

son, 1 the skin was so dark hued as to suggest the color of a mulatto. 
Gradually the patient becomes conscious of an increasing sense of 
chilliness, as if deprived of sufficient body-covering. The itching may 
be absent, be moderate, or be severe. There may be instead sensations 
of stiffness, burning, and tingling. Later the integument seems to 
retract, as if it were insufficient to encompass the body, and becomes 
subject to fissure from extension and contact, while the lower extremi- 
ties may be cedematous. This retraction may be so marked that ectropion 
of the eyelids may ensue, and wide opening of the mouth may become 
difficult. The hairs and the nails lose their lustre and become friable, 
and the hairs often fall though the nails may escape. 

The influence of this epidermal catarrh, involving, as it does, finally, 
every portion of the body-surface, does not fail toward the end to be 
felt by the vital forces. Alternating chills and febrile processes, 
pneumonia of a low grade, colliquative diarrhoea, tuberculosis, sub- 
cutaneous abscesses, bedsores, and even gangrene of the skin may close 
the scene. 

Hebra and Kaposi together had under observation " about fifteen " 
patients affected with pityriasis rubra, who, with a single exception, 
died from its effects. It will thus be seen that the disease is rare. A 
few cases have been reported by British authors. Among Americans, 
Duhring, George H. Fox, of New York, and one of us, have published 
reports of cases. We have had under observation in all six typical 
instances of the affection. The disease is one of early or of middle life, 
and affects preeminently the male sex. 

The progress of the disease is either rapid or slow, lasting for years 
and at times ending with relative rapidity. In the course of a few 
days after its onset the entire body may be covered with the exanthem ; 
yet when the disease is of long duration it may be at times partial and 
at other times general in distribution. There are no red points visible 
as in other forms of scarlatinoid-shaded eruption, and the color when 
the palms and soles are involved only appears after the thick epi- 
dermis of those regions has been shed. Sweat may or may not be 
secreted in the course of the disease. The tongue is bright red in the 
early stages ; later it is covered with a brownish crust ; it occasion- 
ally undergoes exfoliation. There may be a secretion from the skin 
which at times stains the linen. Rhagades may form, especially in the 
palmar and plantar regions. While in the instances of this disorder 
first described in Vienna there was no infiltration of the skin, this 
change has been observed in other typical instances, but usually not 
deeply implicating the corium. The nails may be separated, tilted up 
from the nail-folds, softened, thinned, fissured, " worm-eaten," or other- 
wise altered. The chief systemic symptoms recorded are : languor, 
chilliness, and even severe rigors alternating with febrile temperatures 
of recurrent type, albuminuria, diarrhoea, pulmonary oedema, icterus, 
interstitial pneumonia, bronchitis, and rheumatism. 

The cases reported by English authors are mostly instances of ex- 
foliative dermatitis following lichen ruber, eczema, psoriasis, and other 
simple dermatoses. To this class in particular belong the patients 

1 Edinburgh Med. Jour., April, 1880, p. 879. 



PITYRIASIS RUBRA. 295 

reported as suffering from repeated attacks of the disease ; and those 
also in whom the affection is limited to but few regions of the body, 
such as the palms and soles. 

Etiology — The causes of the disease are unknown. It will be seen 
that the fewness of cases which have been recognized has restricted the 
field for the study of the malady. It is more common in men than in 
women, and in adults rather than in children. The cutaneous phe- 
nomena are due in each case to some constitutional disorder which in 
the early stages frequently presents no other symptoms than those mani- 
fested on the skin, the patient being apparently in good general health. 
Visceral troubles are recognized chiefly at a late period of the malady, 
when it would appear that the cutaneous mischief is sufficiently exten- 
sive to induce them. The wide range of these disorders suggests that 
the cutaneous disease may result from a number of visceral maladies. 

Pathology. — The researches of Hans Hebra 1 demonstrated in two 
cases that in the earlier period of the disease there is an infiltration of 
the integument moderate in degree, succeeded at a later period by 
cutaneous atrophy, in which the rete and papillae of the cor i urn disap- 
pear. The connective-tissue elements undergo sclerosis ; and the 
glands and the follicles of the skin are destroyed. Pigmentation is 
abundant. 

Both Hebra and Fleischmann discovered coincident pulmonary, in- 
testinal, or cerebral tuberculoses ; and Kaposi, in one post-mortem 
examination, established an atheromatous condition of the arteries. 

Baxter, 2 in a patient examined by him, discovered no trace of the 
stratum granulosum, nor was the stratum mucosum completely sep- 
arated from the stratum corneum. There was a gradual transition 
from the polygonal prickle-cells below, which readily stained, to the 
horny cells above, which remained colorless. Flattened and faintly 
stained nuclei lay parallel with the surface, and they could be recognized 
even in the enormously hypertrophied stratum corneum. The papillae 
were enlarged ; the rete-pegs had pushed deeply into the corium. The 
prickle-cells of the hair-sheaths were multiplied. The remarkable con- 
sistency of the thickened corium at the outset of the disease was regarded 
as chiefly due to a fluid exudate, which was observed before death. 

Myelitis was discovered in one case by Jamieson, who has been fol- 
lowed by others in the recognition of central and peripheral neurotic 
alterations. 

Jadassohn found a round-cell infiltration of the papillary body and 

the subpapillary tissue, with increase of the nuclei of the fixed con- 

j nective-tissue cells. The significant features of the process, as Unna 

I points out, are : the persistent hyperemia, the widespread pigmentation 

(possibly associated with the former), and the consequent atrophy and 

tension of the integument. 

Diagnosis. — Many cases reported as instances of pityriasis rubra 
' are not really such. The misinterpreted symptoms are often those of 
j an unusally extensive psoriasis or a chronic squamous eczema, which 
commonly terminates favorably in the course of proper treatment. 

1 Vierteljahr. f. Derm. u. Svph., 1876, Heft 4, S. 508. 

2 Brit. Med. Jour., 1879. 



296 INFLAMMATIONS. 

In lichen ruber the essential lesion is a papule, which even in the 
later extensive scaling of that disease usually may be recognized in 
some part or another of the infiltrated skin. 

Psoriasis rarely extends over the entire surface of the body, but at 
times it is thus generalized. In these exceptional forms a long history 
of the occurrence of typical psoriatic patches may usually be obtained, 
while the bleeding surface beneath the scales and the character of the 
latter will point to the true nature of the disease. Psoriasis occurs in 
healthy, pityriasis rubra in cachectic, constitutions. Extensive eryth- 
ematous or squamous eczema, apart from all other symptoms, can be 
recognized at once by the excessive distress occasioned by the erup- 
tion. The patient lies in bed nursing his or her tender limbs, back, or 
belly. In the early stages of pityriasis rubra the patient may rise, 
dress, and move about with an expression, not of pain, but of listless 
apathy. His scales are not scanty and adherent, but are abundant and 
exfoliate freely. There is, from first to last, no history of moisture. 
In every generalized eczema, at one point or another, there always will 
be a surface which weeps. In its early periods pityriasis rubra can be 
distinguished from pemphigus foliaceus by the absence of bullae and 
of the intolerable stench which is often emitted by the sufferer. When, 
however, there is present merely a generalized exfoliative dermatitis the 
two disorders may well-nigh be indistinguishable. 

Treatment. — Arsenic administered internally seems powerless in 
pityriasis rubra. Cases are on record of fatal results after the exhibi- 
tion of this drug in prodigious quantities for long periods of time. Tar 
externally promises no better result. Kaposi reports a single patient 
relieved by the use internally of carbolic acid. Thyroid extract may 
be tried in chronic cases. 

A roborant treatment, including the employment of cod-liver oil, 
iron, or quinine, is generally indicated, with externally the simplest 
bland unguents, of which vaselin seems best tolerated. It should be 
employed, not merely to soothe, but also to protect the skin. The 
clothing should be ample and un irritating, and the diet selected with 
a view to supporting the strength. 

The Prognosis is necessarily grave. 

PITYRIASIS RUBRA PILARIS. 

(Lichen-psoriasis. Fr., Pityriasis rubra pilaire.) 

This affection has chiefly been described in France by Devergie, 
Besnier, Bichaud, and others. The museum of the Saint Louis Hos- 
pital is provided with illustrations in wax of every phase of the malady. 
In other countries it has until recently either been described under a 
different name or has wholly been ignored. Cases of the disease in 
considerable number have come under the observation of experts in 
America in the past few years. It is claimed that the malady is 
identical with the lichen ruber acuminatus of Hebra. 

Symptoms. — The disease commonly appears as a seborrhoea sicca 
of the hairy scalp, with and without palmar and plantar scaling 



PLATE V. 

Fig 1. 




Pityriasis rubra pilaris. 

Fig. 2. 




Pityriasis rubra pilaris. 



PITYRIASIS RUBRA PILARIS. 297 

patches, though the face may be first to exhibit the signs of the affec- 
tion. The eruption may be preceded by malaise, insomnia, hyperses- 
thetic symptoms, or by a feeling of stiffness in the skin. The first 
symptom is usually the occurrence of very fine desquamation ; soon 
there appear over the surfaces of the fingers, hands, forearms, elbows, 
knees, waist, or belly, minute papules, firm, dry, and silver white, red- 
dish brown, or rosy yellow in color. Each of these papules has evi- 
dently been pierced by a hair, and about its apex where thus traversed 
by the pilary filament there is a delicate sebo-corneous sheath which 
penetrates the hair-follicle for a short distance. These papules may be 
as minute as a millet-seed or larger, but are never of the size of a split 
pea. They become more and more numerous, and appear at times to 
coalesce, and may form a patch covered with fine elevations — conical 
and discrete ; or may be lost in the general scaling, exfoliating, eryth- 
ematous, and shining area. The apex of each conical elevation may 
display an unbroken hair or a mere stump of the same, or a black 
point, the surface presenting then the appearance of the shaven beard. 
The yellowish-red or deep-reddish patches may be the seat of pityriasic 
scaling, or may exhibit separation of the epidermis in large, adherent 
flakes, which especially over the elbows and the knees present the 
appearance of psoriasis. Commonly at the borders of these patches 
are found the initial papules of the affection, still isolated and surround- 
ing characteristic stumps, filaments, or black points of hairs, enabling 
one thus to make the diagnosis with ease. At times the eruption is 
generalized; when the face is chiefly involved the slight crusts formed 
are decidedly of the type of those described under Eczema Sebor- 
rhoei'cum. In many cases the tension of the skin which results produces 
ectropion of the lower lid. Occurring over the hairy scalp, the accumu- 
lated scales and crusts may form a dense and resisting cap which is 
difficult to remove. The nails are usually grayish, yellowish, longi- 
tudinally striated, and roughened. There may also be a coincident 
polytrichia. Important for purposes of diagnosis are the little horny, 
blackish, conical papillse occupying the sites of the hair-follicles on the 
dorsal surfaces of the first and second phalanges of the fingers. These 
usually remain distinct even when the hands are completely invaded. 
The course of the disease is chronic, irregular, and subject to relapses 
and unexpected aggravations. The general health may remain unim- 
paired; the itching is slight. 

Etiology. — The cause of the disease is unknown. It occurs rather 
more often in the male sex, but has been observed at all ages in both 
sexes. 

Pathology. — According to Jacquet, the papule, which is the essen- 
tial lesion of the disease, represents merely keratinization to an unusual 
degree of the epithelial lining of the superior portion of the hair-pouch. 
All the other changes in the skin are subordinate to the epidermal affec- 
tion. Besnier recognizes four types of the disorder, three of which are 
probably represented by somewhat differing processes in the corium 
and epidermis. These types are : the sebaceo-squamous, or pasty 
form ; the reddish, or pityriasic ; the xerodermic, in which the con- 
dition resembles that known as " goose-flesh " ; and lastly, a "mixed" 



298 INFLAMMATIONS. 

form. It is in these clinical pictures that the process, if it be in fact 
unique, may best be recognized, for in them are represented the familiar 
changes seen in eczema, psoriasis, keratosis (lichen) pilaris, xerosis, 
ichthyosis, and possibly a few other affections of the skin attended with 
keratinization of the epidermis. 

Diagnosis. — The disease is to be differentiated from all others by 
the characteristic papule pierced by the shaft, or segment of shaft, of 
a hair. In extensive cases of long standing the identity of the papules 
may be lost in the general scaling process over most of the body ; but 
in nearly all cases they can be recognized on the backs of the fingers, 
as described above. Ichthyosis is congenital ; pityriasis rubra is more 
frequently generalized, and is a grave disorder affecting the general 
health ; while pityriasis rubra pilaris does not always interfere with the 
systemic condition. The disease is by many supposed to be identical 
with lichen ruber acuminatus. For the differences between the two 
maladies the chapter on the last-named disease may be consulted. 
Psoriasis is never characterized by papules with hair-filaments in the 
centre. 

Treatment. — The remedies hitherto found most useful in the local 
management of this disorder are those valuable in the management of 
psoriasis and squamous eczema. Tar, pyrogallol, chrysarobin, resorcin, 
salicylic acid, and the mercurials, with lotions of Van Swieten's liquor, 
are advised, and, when an inflammatory effect is produced, the employ- 
ment of soothing lotions and salves. Fatty crusts, when these are 
abundant, are to be removed by shampooings, as in seborrheic affections 
of the scalp. Internally, arsenic, cod-liver oil, and carbolic acid have 
occasionally proved advantageous. Brocq recommends for internal use 
sodium arseniate in increasingly large doses, but no single remedy is 
known to be efficacious when administered internally. 

The Prognosis is usually favorable. 



EPIDEMIC EXLOLIATIVE DERMATITIS. 

[Epidemic Skin-disease (Savill).] 

During the summer and autumn of 1891 an epidemic disorder with 
cutaneous symptoms developed in several London asylums, infirmaries, 
and hospitals, affecting about five hundred patients. The disease was 
studied with special care by dermatologists and medical men. The 
brief sketch given below is based upon an excellent monograph with 
colored and photographic illustrations by Savill, 1 on various communi- 
cations made on the subject in the columns of the British Medical 
Journal and the London Lancet for 1892, and on the description given 
by Crocker in his treatise. 

The disease occurred in two distinct clinical types, one with catarrhal 
exudation from the skin, resembling the moist forms of eczema, the 
other dry and non-discharging, resembling pityriasis rubra, and, accord- 
ing to Crocker, indistinguishable from that disease. 

1 An Epidemic of Skin-disease resembling Eczema and Pityriasis Kubra, by Thomas 
D. Savill, etc. London, 1892. 



EPIDEMIC EXLOLIATIVE DERMATITIS. 299 

The eruptive features were apparently not preceded by prodroinata, 
but gastro-intestinal disturbance (vomiting, diarrhoea), and in some 
cases sore-throat, either preceded or accompanied the appearance of the 
dermatosis. Except in patients of advanced years, there was usually 
post-occipital and cervical adeno])athy, not to be explained as sympa- 
thetic with a cephalic eruption. The regions most frequently involved 
were the upper limbs, the scalp, and the face ; the lower limbs less 
frequently. 

The skin-lesions were pruritic, and were irregularly grouped, acumi- 
nate papules, with a follicular site. 

The stages of the exanthem, as given by Savill, w r ere : 

a. A papulo-erythematous stage, lasting from three to eight days, 
in which shot-like papules were felt beneath the skin, were dis- 
crete, and were seated on a reddened, thickened, even an indurated 
or oedematous integument. In some cases the onset was in the form of 
marginate and circular nodose patches, resembling those seen in 
erythema nodosum ; in a few cases the resemblance was to ringworm, 
flattened papules enlarging to a circinate annular group with minute 
central vesicles readily ruptured. 

b. An exudative stage, lasting from three to eight weeks, in which 
macules, vesicles, or papules soon formed a confluent eruption, the 
skin being of crimson hue, thickened, and scaling in flakes or in 
lamellated crusts in consequence of the exudation. In the moist type 
the papules developed to vesicles w T ith exudation ; in the dry type the 
exfoliation occurred in pure scales, pints of w T hich in some cases could 
be collected from a patient's skin in a day. In other cases this exfo- 
liation was in the form of an impalpable powder ; it was characteristic 
of all well-marked cases. 

c. A stage of subsidence, in w T hich the disease proceeded to invo- 
lution, leaving the skin at first indurated, polished, and brownish 
in color. In many cases the new skin was raw and parchment-like, 
smooth, shining, and readily fissured, resembling in this respect ich- 
thyosis. In a few instances ectropion resulted, as a sequel of conjunc- 
tivitis. In severe cases the hair and all the nails were shed. There 
was a mortality of from 5 to 13 per cent., death resulting from ex- 
haustion with the usual signs of subsultus, shallow respiration, and 
coma. Complications occurred with pneumonia, gangrene, and albu- 
minuria. A few of the attendants upon the sick (children and patients 
of somewhat older years) were attacked ; but for the most part the 
patients, and especially those succumbing to the disease, were individ- 
uals of advanced years of both sexes, inmates admitted for the man- 
agement of other disorders in the institutions in w T hich the disease 
prevailed. 

The Etiology of the disease was not satisfactorily determined. Cocci 
were isolated and cultivated by Savill and Russell, but the etiological 
importance of these micro-organisms is yet to be demonstrated. The 
influence exerted upon the disease by parasiticides was beneficial to a 
degree ; but this treatment on the whole w 7 as unsatisfactory and chiefly 
amounted to amelioration of the conditions of the skin. 



300 INFLAMMATIONS. 

PARAKERATOSIS VARIEGATA. 

Under this title Unna l and his assistants described two cases of 
patients affected with a dermatosis supposed to be idiopathic, the 
disease occurring in the form of yellowish, reddish, or empurpled 
macules and flat papules constituting an eruption lasting several 
years, and at first affecting the neck, the chest, and the lower limbs ; 
later involving the entire surface of the body with the exception 
of the head, the palms, and the soles. The infiltrated patches, which 
at times contrasted with apparently sunken areas of the intervening 
sound skin, were the seat of a pityriasic desquamation, were distinctly 
circumscribed, and were somewhat variegated in color, suggesting the 
name adopted in describing the affection. Beneath the scales the 
surface was smooth and brilliant. 

LICHEN RUBER. 

(Gr. 7.SIXVV, moss.) 

(Lichen Ruber Acuminatus, Lichen Exudativus Ruber, 
Lichen Psoriasis, Pityriasis Rubra Pilaris. Ger., Rothe 

SCHWINDFLECHTE.) 

Under the term lichen ruber, Hebra was first to describe the disease 
which is now recognized under this title. It is a malady rare of occur- 
rence, and is more often recognized on the continent of Europe than 
elsewhere. Its exact relations to lichen planus and to pityriasis rubra 
pilaris have been the subject of discussion, the results of which have 
not yet settled all the questions at issue. In these pages the disease is 
described as it exists in Europe, while the chapter devoted to Lichen 
Planus is designed to portray this affection as it exists in America and 
as it has been investigated by American observers. 

Symptoms. — The disease is characterized by the appearance, with- 
out prodromal symptoms, of isolated, pinhead-sized, conical, reddish, 
scale-capped papules of considerable firmness, bright red or livid 
in hue, and disseminated over the belly, the chest, the genitalia, the 
extremities, and other portions of the body. In another form of the 
disease these lesions are lighter in color, each with a smooth surface, 
a small central depression at the apex, and a waxy appearance. The 
" nutmeg-grater " effect is usually produced when the finger is passed 
over them. The itching excited may be mild or be severe ; it bears 
no relation to the extent of the exanthem. 

The papules rapidly multiply, forming patches which, by aggrega- 
tion rather than by coalescence, cover large areas of the body, and, 
lastly, its entire surface. Throughout the course of the disease indi- 
vidual papules do not enlarge at the periphery, but they persist as 
such until they are lost in a diffuse, dull-red, infiltrated patch, covered 
with thin, papery, grayish non-adherent scales, beneath which the 
orifices of the hair-follicles are seen to be dilated. Occasionally at the 
border of a patch thus formed, isolated, shining, flattened, or umbili- 

1 Monatsehft. f. prakt. Derm., 1890, vol. xi. 



LICHEN RUBER. 301 

cated papules persist or form circles of densely packed lesions, sur- 
rounding groups in which involution of the lesions progresses, leaving 
pigmented and atrophic areas within. At this stage of the disease the 
resemblance of the symptoms to those displayed in pityriasis rubra 
pilaris is so striking that some authors (Kaposi included) make no dis- 
tinction between the two. 

Whether in the form of lesions last described, or after irregularly 
disposed disseminated patches have been developed, the entire integu- 
ment becomes eventually the seat of extensive infiltration, reddening, 
and scaling. As a consequence fissures form and the distress of the 
patient increases. Bulla? are occasionally observed. 

The skin of the face cracks ; the eyelids are everted or are thickened ; 
the skin of the palms and soles is converted into a leathery tissue ; the 
nails become friable and irregular ; motion at the joints is excessively 
painful on account of the inelasticity of the skin covering the articula- 
tions ; the hairs are thinned and fall ; the extremities are maintained 
in a position midway between flexion and extension. The integument 
is now universally reddened, is covered with innumerable delicate or 
with coarse scales, and, especially upon the palmar and plantar surfaces, 
is thickened by dense infiltration. Over the deeper fissures, extending 
to the corium, form blackish and blood-containing crusts. Emaciation 
progresses pari passu with the invasion of the disease, and death may 
result from exhaustion, intercurrent diarrhoea, or pneumonia. 

Lichen Ruber Planus (as a variety of lichen ruber acuminatus) 
is regarded by most writers as identical with lichen planus. Minute 
yellowish to reddish, firm, dry papules, irregular, differing in shape but 
often polygonal in contour, and varying in size from that of the minutest 
lesions to those as large as a pinhead, rise from the affected surface of 
the skin, often at the site of a hair-follicle whence the pilary filament 
has disappeared. Desquamation does not occur, as a rule, while these 
lesions are isolated ; when confluent there may be considerable scaling. 
The itching may be mild or be of the intensest grade. 

The eruptive symptoms may persist in discrete form as at the 
outset, the exanthem spreading by multiplication of new lesions until 
the entire surface is involved. At points there may be confluence 
with formation of a flattish elevated plaque, light or dark reddish in 
hue, and irregular in outline, with considerable infiltration of the in- 
tegument. Grayish scales are then produced, often with whitish striae 
radiating from the patch. Annular bands and also other figures w r hich 
may be geometrical in contour are thus formed. Occasionally there 
are vesicles and vesico-pustules. Deep pigmentation may succeed com- 
plete involution of the disorder. The wrists, the forearms, the belly, 
the lumbar region, the inferior extremities, and in men the genital 
regions, are most often involved. 

The variations of the affection are: an extreme grade of exfolia- 
tion of the epidermis in large plates from a raw, reddish surface 
fringed with reddish or yellowish scales. On the palms and soles the 
lesions may closely resemble a syphiloderm of these parts, even to the 
minute pits or depressions whence the epidermis has fallen. In occa- 
sional cases, according to Brocq, the papules exhibit blackish points in 



302 INFLAMMATIONS. 

the centre corresponding with the orifices of coil-glands. The disorder 
may affect also the mucous surfaces, as is described in the following 
chapter. The disease even may progress for months or for years with- 
out marked modification; or, on the contrary, the evolution may be 
rapid, the eruptive elements large, the skin greatly infiltrated, the sheets 
of eruption vast, and the general distress great. Bullae and vesico- 
pustular lesions are observed in rare cases. 

Mixed Forms are reported, in which all the symptoms of lichen 
ruber acuminatus and lichen ruber planus have been exhibited in one 
patient. In some instances the one form of disease has been noted 
to precede; in yet other cases another form. Cases are recorded 
in which all the lesions of typical lichen ruber acuminatus and planus 
have been observed coincidently in one patient. 

Unna has attempted to create yet another clinical variety of lichen 
ruber, under the title Lichen Ruber Obtusus. 

In a first variety the lesions are semicircular, pea-sized, flattened, 
polished, waxy papules unprovided with scales, having a bluish-red or 
brownish-red depression in the centre. The itching is usually intense, 
the papules may coalesce, and the eruption may become generalized. 
Pigmentation has been observed after involution is completed. Occa- 
sionally cicatrices have formed. 

In a second variety, the corneous form, the papules are large and 
are seated for the most part on the extremities. The itching is 
intense. As individual lesions increase in size the tinting becomes 
brownish, and over these elements form small, grayish, dry, adherent 
scales, which give a cornified aspect to the surface. Some of the 
papules persist without coalescence throughout the attack. 

These two forms are evidently merely clinical variations of the dis- 
order described fully by authors. 

Lichen Ruber Moniliformis (Kaposi) is an odd-looking disorder 
(of the lichen ruber class), in which numerous node-like masses are 
arranged in lines and chains resembling a jewellers' necklace, with 
flattish, punctiform papules between the nodes, and macules of a sepia- 
brown hue between the lesions. 

Etiology. — The cause of the disease is unknown. Both sexes seem 
to suffer in equal proportion, though it is claimed that more men than 
women are affected. The disease is transmitted neither by heredity 
nor by contagion. In those who display the symptoms of the affec- 
tion external irritation is capable of aggravating the eruption. The 
disease is chiefly encountered in middle-life, from the tenth to the 
fortieth year, but it has been observed as early as the eighth month. 
It is probably a trophoneurosis. Cases have been reported following 
traumatism and shock. Well-marked instances of the disorder have 
been recorded in persons otherwise healthy. Lassar discovered minute 
bacilli in the lymph-spaces, but they have not been shown to be the 
cause of the malady. 

Pathology. — Lichen ruber is a paratypical keratosis of the super- 
ficial portions of the stratum corneum. It is characterized by hyper- 
trophy of the stratum corneum and by incomplete corneous transforma- 



LICHEN RUBER. 303 

tion of the individual elements of that layer, which are larger and 
more polygonal, a feature most noticeable about the sweat-ducts and 
the hair-follicles. The rete is in places enlarged in consequence of 
cell-infiltration, and in places is normal. The upper portion has an 
uneven appearance, as the interpapillary portion pushes slightly down- 
ward, and the increase in size of the other parts is more marked. The 
papillae are increased in dimensions, and their blood-vessels are dilated 
and surrounded by corpuscles. The walls of the sweat-ducts are 
formed of large cells with vesicular nuclei ; corneous cells are heaped 
also about the orifices of the hair-follicles ; the muscle-bundles are 
much hypertrophied. 

Diagnosis. — In psoriasis the discovery of a typical scaling patch, 
often with a clearing centre, should suffice for recognition of that dis- 
ease. The scaling in diffuse psoriasis is also much more abundant. 
In papular eczema the lesions do not persist as such. When these 
two affections are generalized it is claimed by French observers that 
there is always some one area, however small, of unaffected integu- 

, ment. This unaffected area is not to be found in generalized lichen 
ruber; but in such generalized cases the distinction between that 
disease, pityriasis rubra, or dermatitis exfoliativa may be extremely 
difficult if at all practicable. At an early period papules are not seen 
in either of the last-named two disorders. The papules of syphilis 
never scale so generally as those in lichen ruber : moreover, they 
increase in some cases to double their original size, and are always 
accompanied by some other symptom of that disease. In the scaling 
stage of pemphigus foliaceus there are bullse present or there is a history 
of these lesions preexisting. 

Lichen ruber is to be distinguished from pityriasis rubra pilaris by 
the non -limitation of the former to the orifices of follicles ; by the later 
period of its scaling ; by its deeper involvement of the skin ; by its 
greater diffusion over the extensor surfaces of the body ; by its severe 

j grade of pruritus ; by its involvement of the general system ; by its 

! frequent grave issue ; by the deep pigmentation remaining ; and by its 
occasional involvement of the mucous surfaces. 

Pityriasis rosea is a much more superficial and a milder affection ; 
its scales are fewer ; its rarer papules are smaller, and they occur 

I chiefly at the periphery of its oval patches. 

Treatment. — Arsenic, which is of great value, can be employed 
with large chances of success in lichen ruber. This drug is early to 
be given, and persistently pushed notwithstanding neAV crops of lesions 
until the desired result is obtained, and to be continued for several 

i months after all signs of the disease have disappeared. Tonics, when 

' indicated, should always be exhibited. The diet should be generous. 
External treatment is employed chiefly for the relief of pruritic sen- 

i sations. Dusting-powders and ointments prove serviceable. The local 
remedies employed in corresponding stages of eczema may, in brief, be 
here used with advantage, such as alkaline, starch-, or bran-baths, fol- 
lowed by inunction of the skin with salves containing thymol, salicylic 
acid, zinc oxide, bismuth subnitrate, carbolic acid, or benzoin. 

Prognosis. — The prognosis of the disease when it refuses to yield 



304 INFLAMMATIONS. 

to treatment and tends to become generalized is necessarily grave. 
Treatment after the occurrence of marasmus will often prove ineffec- 
tual. The disease is said to be occasionally amenable to energetic 
treatment before it has advanced to the stage of inducing systemic 
exhaustion. 

LICHEN PLANUS. 

(Gr. hetxvv, moss ; Lat. planus, flat.) 

(Lichen Kuber Planus.) 

Since the date of the first description (1869) of this malady by Sir 
Erasmus Wilson it has been the source of considerable discussion due 
to the confusion which has existed in different countries respecting the 
question of its identity with or distinction from lichen ruber planus. 
Lichen planus at one time was rarely reported in America, but it is now 
among the affections occupying a second rank after those of most fre- 
quent occurrence. 

Symptoms. — The elementary lesion of every classically developed 
eruption is a flat-topped, polygonal papule which, when studied in 
different positions so that the light falls aslant upon the surface, exhibits 
a characteristic glistening or shining top of each papule shown in no 
other eruption. 

The papules exhibit a peculiar crimson or purplish shade, and when 
the eruption is plentiful this color is so characteristic that by it alone in 
a well-marked case the eruption may be recognized by the eye before 
individual lesions can be identified. The papules vary in size from 
the head of a small pin to the larger lesions (e. g., of so-called " lichen 
planus obtusus "), in which the papules may be as large as pease or 
beans, and may even assume an annular form or may exhibit about the 
flattened top a ring of minute vesicles or of still finer papules. 

The individual lesions are at first discrete, but they tend to form 
irregularly arranged groups, which may assume a circular shape or that 
of a figure with sharp angles. In no other eruption than lichen planus 
do eruptive elements form in distinctly straight lines and in variants 
from the latter, such as, e. g., a figure representing a digit flexed at a 
right angle. In this way are occasionally formed exceedingly odd- 
looking groups — parallel lines, cockades with scaling crests, rings, 
rosettes, etc. 

As the lesions grow older they almost invariably distinctly deepen 
in shade, from a light-crimson to a dull-purplish hue, and still later to 
even a darker color. In typical cases the lesions of lichen planus when 
actually subsiding or well-nigh gone from the surface of either the chest 
or of the belly are likely to leave a smoky and even blackish hue, which 
is the result of the pigmentation produced when the disease is in great- 
est activity. These sequels of the disease are naturally most conspicuous 
on the lower extremities. 

The eruption is usually symmetrical, though it may occur in patches 
on only one side of the body. The most frequent site of the disease 
is the anterior surface of the forearm, but lesions may develop upon any 
portion of the body-surface, especially the abdomen (more frequently 



LICHEN PLANUS. 305 

its lower third), the extremities (in the point of frequency, first the 
upper and then the lower extremity), the hands, the penis, the back, 
the ankles, the inner side of the knee, and the neck. A typical dis- 
play of symptoms is not often to be seen on the face. In rare cases l 
the eruption is universal. 

When the papules coalesce and also, as happens in extreme cases, 
when they have flattened so as to be indistinguishable before the dis- 
ease has yielded, a crimson-hued sheet or mask of the skin is seen, 
generally characterized not merely by the color of the lichen-papules, 
but also by a silvery sheen, due to thin shining scales which do not 
completely cover, but which supplement, as it were, the empurpled 
patches, beside and over which they form. These scales are not freely 
shed from the surface, but they are firmly attached. 

The greatest variation is experienced in the way of subjective sensa- 
tions. In some patients the eruption is tolerated with but few symp- 
toms of annoyance. In other patients the greatest possible distress is 
occasioned, and no subjects of scabies or of eczema suffer more. The 
eruption of lichen planus, however, is less often scratched than that of 
other cutaneous exanthemata accompanied by severe pruritus. 

The disease is usually chronic in course. Patients of the better 
class commonly reach the end of their sufferings in the course of 
six months or a year. This fact seems to furnish a reasonable basis 
for the belief that treatment has a favorable influence upon the 
malady, seeing that it is not rare to discover untreated patients or 
those in whom the nature of the disease has been long ignored, who 
for two and even more years have suffered from lichen planus in cir- 
cumscribed forms limited to a palm-sized patch over one popliteal 
space or a wrist ; while another for six years and more may have been 
affected over an entire lower extremity or a shoulder. The disease 
may recur, but recurrence is an exception to the rule. In the rarer 
acute forms noted by observers the disease may be relighted to activity 
from a chronic patch ; or it may begin with acute symptoms. 

Lichen planus is remarkable for the exceptions it offers in individual 
cases to the lesions seen in others. Thus, Crocker 2 describes papules 
with a convex instead of a concave top ; and cases in which the lesions 
were soft and compressible instead of possessing the firmness of the 
usual lichen planus nodule. The lesions are occasionally interspersed 
with telangiectases, bullae, etc. 

When the mucous surface is affected the disease develops in whitish 
macules, or striae, or flat papules, the latter aggregated on both sides 
of the tongue, the striae running along the line of the jaws where the 
molar teeth come in contact. The affection in this region has unques- 
tionably often been confounded with leukoplakia (so-called " ichthyosis 
linguae"), elsewhere described. In the mouth the papules of lichen 
planus are in rare instances conical at the apex. 

The disease most often attacks young adults and the middle-aged of 
both sexes. In children, who suffer but rarely, the eruptive features 
show a striking tendency to early flattening, and they thus simulate the 



1 Fordyce, Jour. Cutan. and Gen.-Urin. Dis., 1898, p. 444. 

2 Diseases of the Skin, second edition, 1893, p. 300. 



20 



306 INF LA MM A TIONS. 

macules of much simpler disorders of the skin. Lichen planus of the 
face occurs much oftener in children than in adults. A few cases of the 
disease have been recorded in infants, and these commonly among the 
dispensary class. 

Upon the lower extremities a narrow fillet of typical lesions may in 
cases extend from the heel to the trunk along the line of the sciatic or 
other nerve. After the disease has existed for a long time, a single 
band-like plaque of the disease may lose almost all papular features, 
and come to resemble a deep-purplish keloid-like elevation or flat tumor 
imbedded in the skin. When involution is complete there are usually 
very deep pigmentation and at times slight atrophy. 

Whitish points and streaks are visible at times in the smaller and 
larger lesions, the horny scales projecting from other lesions like thorns. 
Fantastic groups occur on the body in the form of a cockade or in a 
whip-shaped curve; the bands of papules may also assume odd and 
singular figures. At times, especially when the case is one of persistent 
and wholly discrete papules, linear bands of these lesions, one or several 
centimetres in length, of geometrical straightness, may be commingled 
with curved lines and even goitre-shaped figures. 

When there are decided sheets of infiltration they are most conspic- 
uous over the flanks and belly, but they may also be seen elsewhere, 
as, for example, over the extremities. In these cases the very peculiar 
color of the patch with indefinite outlines is characteristic, and is often 
in brilliant contrast with the scales. The scales are of a silvery white- 
ness, very different in hue from the pearl-white or yellowish-white large 
scales of psoriasis, and equally distinct from the branny and yelloAvish 
fine scales of pityriasis rosea. They are by no means freely shed from 
extensive patches, but they adhere and rarely cover the entire patch, 
nor crop out beyond its indefinite border, but produce a species of 
silvery sheen over its central portions. These patches are usually 
symmetrical, as are commonly also the discrete papules of extensive 
development. When either of these forms proceeds to involution the 
scaling ceases, the infiltration subsides, and the intensely deep pig- 
mentation left is characteristic of the disease, being often of a smoky, 
and even of a blackish hue. 

The course of the disease is always toward recovery ; while it may 
endure for months, it rarely lasts for years. 

Variations in the small or the large papules are occasionally observed. 
Minute vesicular points may be visible over their flattened surfaces, or 
there may be seen equally minute keloid-like processes, or reddish points, 
upon or between them, where the vascularity of the tissues beneath is 
apparent. Only as an exception to the rule are the polygonal papules 
clustered about the orifices of hair-follicles, as in pityriasis rubra pilaris 
and lichen ruber. At times whitish points and streaks are left after the 
resulting pigmentation subsides. 

Bullae have been recognized as coincident features in but a few cases. 
Over the palms and soles the whitish spots, produced by exfoliation of 
.the epidermis, may be the most conspicuous symptoms of the disease 
in those regions. 

Lavergne divides all cases of lichen planus into three classes. The 



LICHEN PLANUS. 307 

first is chronic lichen planus, the disease as it is known in its most 
common form ; the second is acute lichen planus, in which the papules 
rapidly develop and form extensive patches, thickened, painful, livid 
red, and abundantly desquamating ; the third form is the lichen planus 
corneus of Vidal, Fournier, and Besnier. This form corresponds with 
the coin- or palm-sized, bluish to blackish, scaling and rugous, tumor- 
like plaques, usually seen on the anterior face of the leg, briefly described 
above. 

Hypertrophic Lichen Planus 1 is characterized by the occur- 
rence of numerous, flat-topped, purplish and brownish-red elevations, 
commingled with sepia-brown pigment-spots. The warty growths may 
be elevated four or five millimetres above the general level of the 
skin. They are seen usually on the legs. The penis is at times sur- 
rounded by papillomata, some of which coalesce to a diffuse infiltration ; 
and the genitalia of women, including the pubic region and hypogas- 
trium, may be studded with pea- to bean-sized empurpled nodules seated 
on a dull-crimson infiltrated integument. 

Etiology. — The causes of lichen planus are obscure. It is often 
difficult to recognize the sources of the disease, but in many cases a 
history of nervous exhaustion can be obtained. Affliction, long-con- 
tinued anxiety, and overwork, especially in cases in which mental effort 
is required for its continuance, are frequent causes of this disorder. 
Many patients are notably well nourished and not lacking in flesh. In 
fact, the combination of a fair degree of nutrition of the body with 
nervous exhaustion is to be recognized more commonly in patients 
affected with lichen planus than in any other affection as annoying and 
persistent. 

Other causes cited are : traumatism (dog-bite — Walters), digestive 
disturbances, malaria, malnutrition, and diseases of the generative or- 
gans. Different opinions are entertained respecting the frequency with 
which the two sexes are attacked. General experience points to the 
conclusions formulated by Crocker, who reports more cases among 
(English) women than among men, as against the statistics of the 
Vienna school, which reverse the figures. The disease among the 
nervously taxed of the well-to-do classes is encountered more fre- 
quently in private practice than among out-patients of public charities, 
who suffer to a greater extent than others from cachexia and malnutri- 
tion. Russell lately reported a case in which the disease followed am- 
putation of four fingers of the right hand. 

Pathology. — Robinson first clearly showed the pathological dis- 
tinction between lichen ruber and lichen planus. His observations 
have been confirmed by those of Boeck, Kaposi, Touton, Weyl, and 
others. 

The first changes noted in the skin are increase in the lumen and a 
sinuous condition of the capillaries supplying the one or two papilla? 
concerned in a single papule. The papilla?, thus largely filled with 
dilated capillaries, contain also a network of fine connective-tissue 

1 Cf. Fordyce and Eddoues, Jour. Cutan. and Gen.-Urin. Dis., Feb., 1897 ; Brit. Jour, 
of Derm., 1898, p. 103. 



308 INFLAMMATIONS. 

fibres, and dense, round cells, which proceed to multiply. Later, more 
papillae and also the epidermis are concerned in this process. In the 
places in which white points are exhibited granules of keratohyalin 
become visible. In some portions of a lichen-papule of medium devel- 
opment the stratum corneum exhibits an external, dark, narrow, and 
firm layer, and beneath it are two to four rows of translucent cells 
forming the stratum lucid am ; but in other parts, and in all parts when 
fully developed, the stratum corneum breaks up into definite lamellae, 
a phenomenon seen in other disorders attended by derangement of the 
keratogenetic function of the skin. The external layer is dark and 
firm when stained ; next below it is a wider layer of swollen cells with 
nuclei scarcely visible, or with relics of liberated nuclei ; and, still 
deeper, a narrow and solid layer beneath which the stratum lucidum 
becomes visible. 

The horny layer is almost entirely absent over the region occupied 
by the cell-packed papule, below which the corium is normal. The 
rete is centrally hypertrophied, especially in the region of the sweat- 
ducts ; its cells above the affected papillae are horizontally flattened, 
and the granular layer is thickened. In some places it is difficult 
in consequence of these changes to distinguish between the rete and 
the corium beneath. The cell-infiltration, composed largely of em- 
bryonic white blood-corpuscles, extends more deeply into the corium 
in the neighborhood of the sweat-ducts. 

Briefly, it appears that the papule of lichen planus is the result of 
a primary hyperaemia of the papillae of the corium ; a secondary thick- 
ening of the lower part of the rete ; a tertiary flattening of the papule 
by reason of the resulting pressure, producing thus the appearance of 
umbilication ; a proliferation of cells in the granular layer, as a result 
of which the deposit of keratohyalin in whitish points or in sheets 
occurs sufficient to produce the clinical peculiarities having that ap- 
pearance (not due, as Neumann supposed, to changes in the sweat- 
glands) ; and coloration of lesions due to both vascularization and to 
escape of blood-corpuscles. 

Diagnosis. — The diagnosis rests upon the characteristic shape, size, 
color, grouping, disposition, and umbilication of the papule of lichen 
planus, which are features not found in any other papular disease. 
Thus, in its size, apex, color, and course the papule of papular eczema 
is quite different from that described above, being brighter, redder, 
more acuminate at the apex, and much more often followed or accom- 
panied by catarrhal symptoms. In psoriasis punctata the scales are 
abundant and readily removed ; the individual lesions are increased 
rapidly by peripheral extension, far beyond the fullest development of 
the papule of lichen. The papular syphiloderm is not, as a rule, pru- 
ritic, not flattened when minute, not polygonal in shape, and not cov- 
ered with a closely adherent horny scale, and it always occurs in 
patients in whom careful investigation discloses other symptoms of the 
disease (mucous patches, adenopathy, etc.). 

The distinctions noted above in connection with lichenification of 
patches of chronic inflammation of the skin are not to be disregarded. 

Treatment. — Roborant treatment by quinine, the mineral acids, 



LICHEN PLANUS. 309 

the ferruginous tonics, and cod-liver oil is frequently indicated. Al- 
though it is claimed that arsenic actually aggravates the disease, 
there is general agreement with Hebra, Wilson, Duhring, and others in 
ascribing to it the most brilliant results obtained in the treatment of 
lichen planus, results far more consistent than are obtained from the 
same drug in the management of psoriasis. Boeck and Taylor give 1 5 
grains (1.) of potassium chlorate in 4 ounces (120.) of water, fifteen 
minutes after eating, followed in a quarter of an hour by 20 drops of 
dilute nitric acid, swallowed in a wineglassful of water. Robinson, in 
generalized hypersemic cases, praises the alkaline diuretics (potassium 
acetate with sweet spirits of nitre), well diluted after meals. Fox 
regards mercury as valuable in the chronic forms of the disease, for 
which also he administers asafoetida. Koebner has injected both pilo- 
carpine and arsenic subcutaneously with success. 

In the way of local treatment the most important measure in acute 
cases is complete protection of the involved surface with powders, oint- 
ments, pastes, soft dressings, or with a non-irritating protective plaster, 
such as zinc oxide plaster or plaster-mull. Unna used 1 part of cor- 
rosive sublimate, 20 parts of carbolic acid, and 500 of benzoated zinc 
oxide salve ; Brocq and Jacquet employ the tepid douche for from two 
to ten minutes once and oftener in the day ; Vidal employs baths of 
vinegar, 1 litre to the bath ; and the external application of 1 part of 
tartaric acid to 20 of the glycerole of starch ; Wilson praises a mer- 
curial salve, 2 grains (0.13) to the ounce (30.). In all severe cases 
attended with considerable pruritus frequent baths of warm oatmeal- or 
bran- water should be ordered, after which the skin should be dried and 
a Lassar paste applied. When later a stronger application is tolerated 
the paste may be medicated with pyrogallol, ichthyol, or the dried 
ferrous sulphate. Tar, thymol, iodine, or chrysarobin may also be em- 
ployed topically with success. Weyl recommends caustic applications, 
as also 1 or 2 parts of beta-naphtol to 90 of rectified spirits of wine 
and 10 of glycerin. In the persistent verrucous types of the disease 
from 10 grains to 2 drachms (0.66-8.) of salicylic acid to the ounce 
(30.) of paste or plaster may be employed. 

Prognosis. — The prognosis is in general favorable, since even cases 
of long standing are usually relieved when the subjects of the disease 
are placed under conditions favorable for recovery. It is always to be 
borne in mind, however, that in individual cases in which the patient 
is neurasthenic the eruptive symptoms may persist for years, accom- 
panied by intense itching and a consequent teasing of the nervous cen- 
tres. In this class of subjects it is generally well to make a guarded 
prognosis, and to pronounce upon the future with just reserve. 

Lichen Annularis (Ringed Eruption of the Extremities) 
is a title given by Galloway 1 to a case in which several lesions having 
pale, irregular, elevated borders showing circular or circinate outlines, 
developed about the joints of the hands. The border was slightly 
elevated, about three millimetres in breadth, smooth, and not reddened. 
The skin of the enclosed area was almost sound, but showed slight 

1 Brit. Jour, of Derm., 1899, p. 221. 



310 INFLAMMATIONS. 

signs of atrophy when the original process had undergone involution. 
The histological structure closely resembled that of lichen planus. The 
lesions flattened rapidly under the application of salicylic acid in oint- 
ment. A similar case is under our observation. 

Lichenification. — In certain portions of the integument, usually 
definitely circumscribed and of a limited area, a significant change 
often occurs, which has been designated by the French lichenification, 
on the ground that this is not a form of lichen planus, the term which 
they employ designating the change which is progressing in the skin. 
It is possible that this condition represents a stage intermediate between 
chronic inflammation and a specialized dermatosis. In any event it is 
necessary to distinguish between the two in establishing a careful diag- 
nosis. In such patches (marginate eczema, nevrodermite, etc.), found 
particularly about the flexures of the joints, the fork of the thighs, the 
back of the neck, and elsewhere, the surface of the skin is seen to be 
studded with dull-reddish, closely packed, flat-topped, often polygonal 
papules, which strongly resemble those occurring in lichen planus, and 
yet which seem to be symptoms of the chronic inflammation present 
rather than of an affection of distinct type. 

ECZEMA. 

(Gr., ek tjeo, to boil forth.) 

(Ger., Eczem; Fr., Eczema.) 

Eczema is distinctly a protean disease. It cannot, therefore, be 
defined or described satisfactorily in a single paragraph. It is not 
only protean in its clinical manifestations, but its causes are varied, 
numerous, and usually complex. In histological detail different types 
of eczema vary considerably, yet all probably result from one common 
pathological process. Clinically, though a dozen successive cases of 
eczema may present wholly different pictures, yet they all have some 
characteristics in common and the diagnosis in most cases is not diffi- 
cult. It has often been described as a catarrhal inflammation of the 
skin, but many cases of dermatitis now generally classed as eczema 
show no vesiculation or other evidence of discharge, and cannot properly 
be considered catarrhal in nature. As a rule, eczema shows at some 
time in its history more or less serous discharge, either in the form of 
vesicles or in a denuded oozing surface ; but some cases of erythematous 
and papular eczema persist as such throughout their entire course, aud 
never produce an exudate upon the surface. 

A vexed and unsettled question among dermatologists is the rela- 
tion of eczema to other forms of dermatitis. The study of the exact 
pathological changes in the skin has led to the inclusion under eczema 
of conditions formerly considered distinct affections. On the other 
hand, many writers, especially in England and France, are now endeav- 
oring to exclude from eczema every dermatitis for which a definite 
cause can be found. Eczema is a dermatitis, and it is not possible to 
say for every case which title is the more appropriate. A convenient, 



ECZEMA. 311 

arbitrary division, which is followed in these pages, classes under der- 
matitis those forms of inflammation of the skin which result from 
recognized, external causes, and which subside on the removal of the 
cause. Such definite and independent affections as dermatitis herpeti- 
formis or dermatitis repens are, of course, considered separately. 

Symptoms. — Eczema is one of the diseases of the skin of most 
frequent occurrence. In the statistics gathered by medical men it 
would seem to rank first in the order of frequency, forming from 20 to 
40 per cent, of dermatological cases reported. It is undoubtedly true 
that acne is a more common affection than eczema, but as many subjects 
of acne never deem it necessary to submit to treatment for its relief the 
records of such cases do not figure in dermatological statistics. This 
fact being noted, eczema may be regarded as the disease of the skin for 
which most frequently the practitioner of medicine is consulted. By 
as much as inflammation is the commonest accident of other organs of 
the body, by so much is its enveloping organ subject to the same path- 
ological process. 

The accepted signs of inflammation of any given tissue are usually 
named as increased heat, redness, pain, and swelling. These symptoms 
are present to some extent in every eczema though modified by the 
anatomical" peculiarities of the organ in this case affected. The surface 
involved in typical eczema always shows some elevation of tempera- 
ture, it being slight in chronic, but more marked in acute, cases. Red- 
ness, varying in shade from the bright red of the acute to the dull red 
of the chronic forms, is also true of the eczematous skin. Pain here is 
represented by a sensation of itching which is almost invariably present 
and may vary from a slight annoyance to an almost intolerable distress. 
It is commonly intermittent or paroxysmal in character and is usually 
worse at night. In some instances, especially in acute and erythemat- 
ous types, the sensation of burning or smarting may be more marked 
than that of itching. Occasionally an eczematous skin is hypersesthetic 
and exceedingly sensitive to contact with even the blandest substances. 
The degree and character of the subjective sensations in eczema depend 
largely upon the location, type, or severity of the disease, but also to 
some extent upon the general condition or peculiarities of the indi- 
vidual. The fact that itching rather than pain accompanies inflamma- 
tory disorders of the skin is due largely to the fact that the skin is 
exposed to the air, and its increase in bulk is not opposed by contigu- 
ous parts. Inflammation of the inner skin of the body, that of the 
lining membrane of the stomach or of the intestines, is generally char- 
acterized by the occurrence of severe pain. In acute types of eczema 
there is often some cedematous swelling, together with slight infiltration 
! of the skin. In chronic forms the infiltration and thickening of the 

skin are more pronounced and may be excessive. 

f In addition to the symptoms of heat, redness, itching, or burning, 

I and swelling or thickening of the skin, found in every case of eczema, 

j the great majority of eczemas have certain characteristics in common. 

The course of the disease is capricious, not only the severity of the 

process, but often the type of lesion changing frequently and rapidly. 



312 INFLAMMATIONS. 

This is most conspicuous in children and in others having delicate 
skins, and in those cases in which the affected areas are not protected 
from atmospheric and other external influences ; it is unusual for any 
eczema to pursue an even course. Daily variations in severity, with or 
without change or modification of type, are not uncommon. Apparent 
recovery is frequently followed by a relapse which may develop fully 
in a few hours and without apparent cause. 

Aside from some cases of erythematous and papular eczema, which 
may persist throughout without change of type, eczema is notably a 
polymorphic disease, presenting in irregular succession or in varied 
combinations : erythema, papules, vesicles, pustules, crusts, scales, fis- 
sures, excoriations, or denuded and oozing surfaces. Even in the mildest 
cases the skin is slightly infiltrated, while in some severe, chronic forms 
the thickening may be excessive and deforming, or there may be hyper- 
trophy of all the layers of the skin producing wart-like growths 
(Eczema Verrucostjm). 

The serous discharge which is present during at least a part of the 
course of most eczemas is characteristic, and stiffens articles of clothing 
on which it dries. It may be imprisoned in vesicles, but more com- 
monly oozes from a denuded surface or from minute excoriated points 
which represent abortive or ruptured vesicles. 

Like all other inflammations, eczema may be acute or be chronic. 
Like all others, too, the acute may precede, and the chronic may follow, 
or the reverse may occur. The disorder, originating in subacute or 
insidious forms, may become chronic, and then, as the result of fresh 
or of more severe irritation, may develop the acutest symptoms. Fre- 
quently, as in the eczema of children, the disease may be chronic in 
respect to duration, yet most of the time present acute symptoms. As 
a rule, eczema does not undergo spontaneous recovery, but tends rather 
to remain indefinitely and to extend either by involving contiguous 
surfaces or by developing in new areas. The disease is commonly 
more or less local, appearing in one or several irregular and usually ill- 
defined areas, but may be general or even universal. It apparently 
occurs independently of all other disorders, the general health remain- 
ing unaffected even in severe forms of the disease ; or it may be but the 
external expression of constitutional disturbance. 

Clinically, several types of eczema can be recognized. These types 
require separate description. It should not be forgotten, however, that 
in the majority of cases eczema is a complex process, in which two or 
more types are seen, either in succession or simultaneously. Though 
several forms of eczema frequently coexist, it is usual for one type to 
predominate, either throughout the course of the disease or for certain 
periods. 

[A] Eczema Erythematosum. — This form of the disease is most 
common on the face, especially in individuals exposed to wind and 
weather or to direct heat, but it may appear on any part of the body, 
and is frequently seen on the palms, the soles, and in the genital regions. 
It begins usually as a diffuse, ill-defined area of redness, less frequently 
as a number of coin-sized macules or erythematous spots, which may 
coalesce or remain more or less distinct. Swelling and infiltration are 



ECZEMA. 313 

present in varying degrees. In acute cases the oedema may be exces- 
sive, sometimes closing the eyes. In the subacute forms, which are 
the more common, there are less oedema and more infiltration and thick- 
ening of the skin. 

The sensation of itching, which is so characteristic of most forms of 
eczema, is usually excessive, though it may be largely or wholly sup- 
planted by one of heat or of burning. This is especially true when the 
process is acute in character. The color varies from a bright to a dull 
or purplish red, depending upon the severity of the disease, its location, 
and the peculiarities of the individual ; and inasmuch as the condition 
is more frequently observed in middle-aged adults with darker hue of 
integument than in early life, the color of the part is often noticed to 
be of a dull-crimson shade. At times the coloration is irregularly dis- 
tributed, producing a mottled appearance, bright at one point and dark 
at another. A yellowish tinge usually indicates that the process is 
combined with seborrhcea, producing the combination described in 
another chapter as eczema seborrhoei'cum. 

The erythematous surface is modified, as a rule, by more or less fine 
desquamation, which begins a few days after the occurrence of the first 
erythema, and persists to the end of the disease. There is no discharge, 
unless, as frequently happens, the type changes to a moist form, but 
when the disease occurs on apposed surfaces, as in the axilla, under the 
breasts, or about the genitals, the epidermis may be destroyed by 
maceration and friction, and leave a denuded, oozing surface. The dis- 
ease may pursue an acute course, terminating in exfoliation and gradual 
resolution, or changing to the papular, vesicular, pustular, or mixed 
types. More frequently it persists and becomes chronic, both in the 
intensity of the process and in its duration. The skin then becomes 
more infiltrated and thickened, and may present voluminous firm folds, 
which are very conspicuous and often deforming. Exfoliation may be 
so prominent a symptom as to suggest for the condition the name of 
Eczema Squamosum or Exfoliativum. The area involved is fre- 
quently better denned than in other forms of eczema, and though the 
condition may remain limited to its original site for months or years, 
it has a decided tendency to extend either contiguously or by the 
formation of new areas. The intensity of the process may change 
frequently and rapidly. It is usually aggravated by exposure to 
heat, cold, or wind, or by any condition which favors congestion of 
the part. Scratching of the surface involved produces a change in 
the symptoms which the skilled eye will promptly recognize. Minute 
superficial losses of tissue are then visible here and there upon the 
surface; the more recent lesions having a reddened floor possibly hidden 
beneath a thin blood-scale, the older being surmounted by a light 
yellowish-red crust. The scratch-lines, often recognized elsewhere, are 
here less evident. 

Like all other varieties of eczema, this form is extremely liable to 
recrudescence and relapse. In advanced life traces of the disease may 
be visible for years. 

[B] Eczema Papillosum. — Under this title are classed all those forms 
which have been described as Lichen Simplex, Lichen Ecze- 



314 INFLAMMATIONS. 

matodes, Eczema Lichenoides, etc. It is of great importance that 
there should be a distinct and general recognition of the fact that in 
exceptional cases eczema may exist from first to last as a dry infiltration 
of the integument, for there is perhaps no one of the various manifesta- 
tions of the disease that is so frequently confounded with other widely 
different affections. 

The papules are acuminate, pinhead-sized or larger, colored in 
various shades of red to a dark lurid shade, and are usually seated 
upon a reddened and thickened base. They are generally discrete, 
though often set closely together, are accompanied by an intense form 
of itching; and of all eczematous lesions are most likely to be irritated 
by scratching. Their summits are torn, often to such an extent as to 
bleed, the blood drying in minute crusts on the apices of individual 
lesions. Existing papules may persist for weeks or may disappear 
and be replaced by others. They may completely coalesce to form 
irregular, thickened, elevated, pea-sized or larger patches, covered with 
scales. The areas involved in papular eczema are often fairly well 
defined in outline. The extent of surface affected varies, the disease 
being in some cases largely diffused over various portions of the body, 
but usually limited to small single patches no larger than the size of 
a small coin. Such patches, covered with a single or with several 
groups of reddish papules, may continue to torment the patient for 
long periods of time, or, being at one time relieved, may recur with each 
aggravation of the malady by the exciting cause. Papular eczema is a 
dry manifestation of the disease, and is thus most frequently noticed 
upon the drier portions of the integument. These parts are the surfaces 
of the limbs, the back of the body, and, in particular, the scrotum. In 
the latter region the papules are large and often flattened. If the moist 
forms of eczema are most frequently seen in early life, it is none the 
less true that the dry forms are the most common in adult life or in 
advanced years. 

It should not be forgotten, however, that the papules here described, 
when there is free exudation beneath the surface, may exhibit pin- 
point-sized vesicular summits which may develop into minute or larger 
pustules. A patch of papular eczema, where no vesiculation nor pus- 
tulation has been observed, will, if sufficiently scratched, ooze with 
moisture, the serum escaping from the abraded surface. There are, in 
fact, few scratched eczematous surfaces which will not moisten a dry 
handkerchief applied to the part. This weeping condition attracts the 
attention of 'patients themselves, who complain of it in describing their 
symptoms. A species of relief from the pruritus is thus obtained ; and 
in aggravated cases patients will scratch or rub or otherwise irritate the 
diseased patches, not merely for the purpose of gratifying the intense 
desire to assuage the itching, but also to induce serous exudation for the 
sake of the relief it affords. The secretion when in contact with linen 
cloths stains and stiffens them, very much as seminal fluid leaves its 
traces upon clothing. 

Resolution of papular eczema is accomplished after the formation 
of scales, the tissues beneath the latter assuming more and more the 
appearance of healthy skin. 



ECZEMA. 315 

[C] Eczema Vesicuiosum. — This expression of the disease is char- 
acterized at an early period by the formation of minute vesicles. It 
is a matter of importance, however, to recognize the fact that the 
vesicular, like the erythematous, is but one of several manifestations 
of this singularly protean affection. Long after the appearance of the 
treatises of early English dermatologists the term " eczema " was very 
generally limited by physicians to the vesicular phases of the disease ; 
it is to the Vienna school that we are largely indebted for the recog- 
nition of the fact that these simultaneous or successive features, 
presented often in the same individual, really belong to one and the 
same malady. To limit the name eczema to-day to its vesicular variety 
alone would be to relegate the student of diseases of the skin to the 
misty uncertainties of the first half-century of dermatology. 

The clinical features of vesicular eczema are chiefly due to the 
acuity of the inflammatory process present, and to the consequent free 
exudation of serum of the blood from the vesicular plexus immediately 
below the pars papillaris of the corium. The involved surface usually 
feels at the outset hot, itchy, or unusually sensitive, and soon after 
becomes more or less intensely reddened, the result of hyperemia and 
subsequent exudation which may last for one or for several hours. 
Poppy-seed- to grape-seed-sized vesicles then become visible on this 
reddened base. The lesions may be closely packed together, or be 
discrete, or may be so abundant as to coalesce, a frequent behavior of 
all vesicular lesions. Each vesicle is filled with a droplet of clear 
serum imprisoned beneath the most superficial layers of the epidermis. 
This vesicle is readily ruptured, and if this rupture does not speedily 
occur as the result of accident, the lesion bursts spontaneously, and its 
limpid contents are then poured out upon the surface of the integu- 
ment. The quantity of the fluid thus exuded is in excess of that 
originally contained in the small vesicular chamber. This excess is 
due to the fact that the elevated, macerated, and broken epidermis 
no longer presents an obstacle to the outflow of serum from the 
engorged vessels beneath. Minute and even large drops of a clear fluid 
of syrupy consistency can be seen collecting at the points where the 
solution of continuity has occurred. If with a slip of bibulous paper 
the first drop be removed, its place is visibly filled by a second. Crops 
of new vesicles succeed the first, each crop being followed by the train 
of symptoms described. The vesicles are usually short lived and often 
have disappeared before the patient is seen by the physician. In other 
instances the destruction of the epidermis by rubbing or scratching, or 
by an abundant and rapidly formed exudate, allows the escape of the 
fluid without previous vesicle-formation. The discharge dries rapidly, 
when exposed to the air, in light-yellowish crusts which are rarely 
bulky. Clothing on which the fluid dries is stained and stiffened. 
The weeping at many points of the surface affected is so prominent a 
feature of the disease that it has led several authors to describe eczema 
as invariably a catarrhal disease of the skin. There are, without 
question, forms of this disease in which the history is throughout 
entirely different from that just described, in which no evidence of 
discharge can be appreciated from first to last, and yet in which, by 



316 INFLAMMATIONS. 

artificial measures, the so-called " catarrhal " features can readily be 
produced. 

The contour of the affected patch or patches is seldom well defined, 
the pathological portions imperceptibly shading into the sound skin. 
The color of the area thus diseased varies according to the stage of the 
process, being at one time of a vivid red, at another yellowish, and, 
* when covered with crusts or scales, undergoing a corresponding change 
of hue. Infiltration of the skin occurs rapidly, so that when a portion 
of the affected integument is pinched up between the finger and thumb 
is is found to be thicker and less elastic than normal. This form of 
eczema may persist or recur in a single small area, or it may spread and 
become diffused or even generalized. It appears commonly on the 
flexor and other surfaces where the skin is thin. 

The subjective symptoms of vesicular forms of eczema are more or 
less intense itching and often burning. In very acute forms there is 
considerable soreness, the patient managing the affected part with as 
much care as if it were a fractured limb. In exceptional cases, more 
frequently observed in children, there is a sympathetic febrile disturb- 
ance of a mild grade. 

As resolution approaches, all the symptoms described above gradu- 
ally decline in severity ; the serous discharge diminishes, the redness 
fades, the limits of the involved area become less distinct, the crusts 
loosen and fall, and beneath the scales which have taken the place of 
the oozing and broken epidermis a new and tender epithelial covering 
is produced. As a rule, for weeks after the process has completely 
ceased the newly formed epidermis has a slightly reddened and tender 
appearance, though complete resolution is followed by no permanent 
sequels. Instead of undergoing resolution the condition may terminate 
in eczema rubrum, in eczema squamosum, or in eczema pustulosum, 
this last form being ordinarily due to pus-infection. 

These then being the typical phases of vesicular eczema, clinically 
the picture may be quite different from that described. The types here 
given are convenient for analysis and study, however much they may 
be commingled and obscured in the inflamed integument. Like the 
erythematous, the vesicular forms of eczema may precede the others, 
and, becoming chronic, may torment the suffering patient continuously 
for long periods of time, or may yield, only to reappear at irregular 
intervals. 

[D] Eczema Pustulosum (Eczema Impetiginoides, Impetigo Ec- 
zematodes). — This type may originate in one of the other forms of ec- 
zema, in consequence of the severity or acuity of the process, or be the 
result of secondary pus-infection, or pustular lesions may rapidly form 
at the onset. Usually there is first seen a crop of minute vesicles, which 
enlarge and become distended with puriform contents. These pustules 
either accidentally or spontaneously burst, and the fluid with which 
they were distended dries into yellowish-green or darker colored 
friable crusts. In aggravated cases the purulent matter seems to 
form directly upon the involved surface. If the process be long 
continued, infiltration occurs, and the itching, which in all varieties of 
the disorder is a characteristic feature, is awakened as an accompany- 



ECZEMA. 317 

ing symptom. The itching, however, is rarely of the peculiarly 
aggravated type accompanying the erythematous and papular phases. 
Pustular eczema is most frequently encountered on the head, and 
in constitutions that do not readily resist the invasion of pus-cocci. 
When existing on the scalp and the face there is most commonly 
an involvement also of the sebaceous glands, the secretion of which, 
altered by the periglandular inflammation, is added to that naturally 
produced by the exudative process. Singular shades of mixed yellow 
and green and even black, are then to be distinguished in the re- 
I suiting crusts, which later desiccate and fall, leaving a reddened 
and tender new epidermis beneath. The condition is frequently seen 
on the scalp and face of infants, and is then popularly called " milk- 
crust." 

The four types of eczema considered above are, as has been stated, 
j sometimes encountered in practice as distinct and unmingled forms of 
cutaneous disease, some of them more commonly than others. To pre- 
; sent, however, a picture of eczema as it is seen clinically it must be 
i understood that these several forms, useful in the analytical study of 
| the disease, often become, in actual observation, well-nigh inextricably 
commingled. " Observation of the natural course of an attack of 
eczema," said Hebra, " furnishes the most unassailable proof of the 
| connection between its various forms. In one case an eruption of 
vesicles begins the series of symptoms ; in another it is preceded by 
the appearance of red scaly patches or groups of papules ; or vesicles 
I and papules are developed together, some of the former rapidly chang- 
ing to pustules and forming yellow gum-like crusts by the drying up 
of their contents/' It is this constant interchange of features that dis- 
tinguishes most eczemas from all other inflammatory affections of the 
skin. 

The name Eczema Kubrum has been given to the red and angry 
form of the disease, which, because of the free exudation of serum 
; from the surface, has also been termed Eczema Madidans. In 
this form the highly inflamed, intensely red and wounded integument, 
I the horny layer of which has been destroyed and removed, pours 
out freely upon the surface a thick, gummy or syrupy fluid, which, if 
i artificially removed, leaves behind it a swollen, angry, and still dis- 
charging skin ; or, being permitted to dry where it has formed, covers 
j the surface with large flake-like crusts, which may be thin and yellow, 
or thick, dark-colored, and often blood-stained. The crusts may re- 
I main but a few hours before an excessive outpouring of the fluid re- 
i moves them. There are thus displayed in frequent and rapid alterna- 
! tion the discharging and the crusted surface. Eczema rubrum may 
I occur on any part of the body, but especially in the flexures of joints 
or where two surfaces come together; another common site is on 
the legs of elderly people or of those who stand much of the time. In 
this region it is exceedingly chronic and rebellious to treatment, and 
eventually is accompanied by a great degree of infiltration and thick- 
ening which may go on to hyperplasia and produce a condition simu- 
lating elephantiasis. 



318 INFLAMMATIONS. 

Eczema Squamosum, or Exfoliativum, is a type of the disease 
marked by more or less redness, infiltration, and exfoliation of the 
skin. The scales are usually small, thin, whitish, and adherent. They 
may be scanty or quite abundant. Squamous eczema represents a low 
grade of inflammation, and is present as a transitory condition during 
a part of the period of resolution of all other types of the affection. 
It frequently persists, however, in the form of irregular, usually ill- 
defined, more or less infiltrated, dry, scaly patches. It is seen com- 
monly on the neck and face, at the border of the scalp, and on the 
limbs. 

Eczema Fissum, Eczema Rhagadiforme. — In eczema of the 
hand the movements of the fingers often produce fissures or cracks in 
the inflamed and infiltrated integument, and to those fissured forms the 
titles named above have been given. Fissures are observed wherever an 
eczematous disorder has so impaired the elasticity and extensibility of 
the skin that its necessary movements, especially about the joints, tear 
and stretch the thickened integument. It is thus seen not only on the 
hands, but also on the arms, the feet, and about the ankles, the resulting 
rhagades being, at times, the most painful of all the complications of the 
malady. It is frequently seen about the mouth and anus. Occurring 
upon the bodies and the hands of those who are compelled to come in 
contact with irritating substances, this form of the disease finds its 
severest expression. Mild, commingled forms of squamous and fis- 
sured eczema occur quite commonly on the hands and faces of persons 
whose skin is thin, tender, and poorly nourished, or exposed to wind, 
harsh soaps, hard water, chemicals, and other irritants. The condi- 
tion is popularly known as Chaps or Chapping. 

Eczema Craquele is a rare form of eczema described by French 
writers in which a reddened surface is covered with large, thin flakes, 
or scales, separated and outlined in polygonal areas by superficial cracks 
or fissures. The condition usually involves a considerable surface of 
the skin, and is accompanied by itching and burning and in most cases 
by hyperesthesia and an extreme sensitiveness to temperature-changes. 
It occurs chiefly in neurotic subjects. 

Eczema Intertrigo is a name applied to that form of intertrigo 
which, surpassing the limits of hyperemia, results in an exudative 
process. Reference is made to this possibility in describing the symp- 
toms of erythema intertrigo. In eczema intertrigo the symptoms are 
usually those of diffused redness of surfaces of the skin in close appo- 
sition, macerated by previous transudation of sweat, and weeping with 
the serum which oozes from several abraded points or patches. It 
chiefly attacks the obese of both sexes and all ages, and in advanced 
years the gouty. 

The flexor surface of the extremities, especially in the vicinity of 
the joints, as well as the inframammary regions, the interdigital surfaces 
of the feet, and the axillary and inguinal spaces, are particularly prone 
to exhibit symptoms of this disease. In all such localities the alter- 
nate tension and relaxation of the integument serve, when the limbs are 
in motion, to increase the pruritus, and, correspondingly, to aggravate 
the disease. Often a certain proportion of symmetry can be perceived, 



ECZEMA. 319 

the two popliteal spaces, for example, being simultaneously affected, 
though each in a different degree. The parts most favorable for the 
complications of intertrigo are those nearest the trunk, where moisture 
and heat are greater, as the groins and the axilla?, while the elbow and 
popliteal spaces are more frequently dry, exhibiting papulo-squamous 
ridges in lines at right angles to the axes of the limbs, with hypersemic 
patches on either side. 

Eczema Verrucosum, or the wart-like form of the malady, is 
occasionally observed, especially upon the lower extremities, in middle 
life or in advanced years, as the result of long-continued disease. The 
integument becomes thickened and so hypertrophied as to suggest the 
appearance of warts closely packed together in a circumscribed patch. 

Eczema Sclerosum is a form of the disease most frequently 
observed upon the palmar and plantar surfaces, a condition referred 
to in the paragraphs relating to Asteatosis. In eczema sclerosum is 
presented a densely thickened inelastic integument, suggesting the con- 
dition of tanned leather, without the occurrence of any of the other 
lesions of eczema described above. As a consequence, the power of 
perfect extension of the digits is impaired. 

Tuberculous Eczema of Nurslings, so called, is a term which 
has been applied to eczematoid eruptions about the mucous orifices of 
the eyes, nose, mouth, and ears, occasioned and sustained by morbid 
conditions of, and serous discharges from, those parts (otorrhoea, rhin- 
itis, phlyctenular keratitis, etc.), and accompanied by oedema, vesicula- 
tion, and enlargement of lymphatic glands. The disease is character- 
ized by rebelliousness to treatment and chronicity of course. This 
disorder is improperly named, since tubercle-bacilli have not been rec- 
ognized in its lesions; and because the symptoms above enumerated 
may all be present when there is simply systemic nutritive failure and 
when no tuberculosis of other organs is present. 

Eczema Diabeticorum (Fr., Diabetides).— A singularly well- 
defined eczema is to be recognized about the genital organs of both 
sexes, but more particularly of women, accompanied by the most 
atrocious pruritus, excoriations produced by scratching, and enormous 
tumefaction of the anogenital and surrounding integument. The local 
symptoms are chiefly those of eczema erythematosum, the surface 
being, as a rule, destitute of either vesicles or pustules. There are 
often a profuse serous discharge, considerable infiltration, and the pro- 
duction of inflammatory nodules over the engorged surface. 

These cases fall within three categories. In the first and rarest the 
patient has saccharine diabetes of long standing, and the parts are 
simply irritated by the passage over them of urine charged with sugar. 
; In the second and commoner form there is a temporary glycosuria, 
I either produced by the local eczema or indirectly resulting from the 
\ latter, and yet due to transitory causes, since both the eczema and 
, saccharine urine disappear with relative rapidity when the local treat- 
ment is combined with the dietary appropriate for the diabetic. In a 
!last group the sugar-fungus (Torula cerevisice) finds a nidus in the skin. 
Eczema Folliculorum. — Morris first described under this title 
a form of eczema which begins as an inflammation of hair-follicles. 



320 INFLAMMATIONS. 

Each inflamed follicle projects from the surface in the form of a red- 
dened papule about which the skin becomes hyperemia As the 
process spreads centrifugally by the involvement of adjacent follicles, 
the centre undergoes involution with desquamation, and a gradual 
change in color from red to yellow. This condition is found most fre- 
quently on the extensor surfaces of the legs and the arms, in multiple, 
scattered patches. The itching may be intense. This form of eczema 
is obstinate, and usually recurs. Morris considers it parasitic in origin 
and allied to sycosis. 

Eczema Parasiticum. — Under this title is included a large num- 
ber of cases the exact relations of which to the recognized types of the 
disease are still indeterminate. It is well known, for example, that the 
surface of the human body in health is the habitat of an enormous 
number of different parasites which are, for the most part, harmless or 
are effective as agents of disease only under certain specially favorable 
conditions of the body. Cultivation-experiments with the flora found 
on the eczematous skin have revealed a large number of parasites which 
together, if not singly, may be effective in producing some of its dis- 
tinctive features. According to Unna, eczema is in these cases a 
chronic parasitic catarrh. 

Eczema Marginatum is considered under the head of ringworm. 

Eczema Seborrhceicum is described separately under that title. 

Acute Eczema. — An acute attack of eczema may be ushered in by 
malaise, chilliness, or the recognized symptoms of the febrile state. With 
or without these prodromata the affected portion of the skin-surface 
becomes the seat of a burning sensation which is soon succeeded by 
redness and swelling. This tumefaction may occur upon one or upon 
several portions of the body at the same moment of time, and the dis- 
ease throughout be limited to a single area or to several spaces ; or it 
may extend from one to other or all regions. This extension may pro- 
ceed by continuous development of the disease along the surface, or an 
eczema of the thigh may suddenly be followed by an eczema of the 
face, and this by an eczema of the scrotum. Extension of eczema by 
the last-described course may occur when no constitutional cause can 
be discovered and undoubtedly is due largely to the extraordinary 
sensitiveness of the skin when involved in an acute attack, in con- 
sequence of which the slightest friction, or even reflex irritation of 
the blood-vessels produces a new focus of the disease at a distant point. 
This consideration is of special importance. Patients will frequently 
point to an acute eczema upon several portions of the body widely 
separated one from another, and will urge this as an irrefutable argu- 
ment in favor of the fact that they suffer from some " poison in the 
blood/ 7 

The tumid and erythematous surface above described soon assumes 
the features of one or more of the types of eczema outlined in the 
preceding pages. In this manner the evolution of the disease occurs, 
and may continue for weeks, the patient, if unrelieved, being tormented 
by the itching, and, if the disease be extensive, being prevented from 
attending to his usual vocation. Acute eczema of severe grade will 



ECZEMA. 321 

frequently prostrate a strong adult, confining him to his bed-chamber 
and often to his bed. When there is a simultaneous febrile process the 
emaciation and adynamia are proportioned to its severity. Weeks and 
even months may elapse before recovery can be pronounced complete, 
subacute patches of the disease lingering here and there upon the sur- 
face, crust-hidden, scale-covered, occasionally oozing from recrudescence 
of symptoms. Recovery, even when complete, leaves the patient, it 
should never be forgotten, with a skin sensitive to irritation and more 
prone to a fresh attack of the disease than one long virgin of an inflam- 
matory process. 

Such is the course of an attack of acute eczema of severe grade. 
It must be remembered, however, that the process may be mild and 
subacute from the beginning, or again that a circumscribed patch of 
skin may exhibit all the features of vesicular eczema in an acute form, 
and under the influence of appropriate treatment may satisfactorily be 
relieved in the course of a few days. Lastly, acute or subacute eczema 
may be followed by chronic forms of the disease, the one passing into 
stages of the other by scarcely definable gradations. 

Chronic Eczema. — The symptoms and pathology of chronic eczema 
are largely those of the acute form of the disease. The chief differ- 
ences to be noted relate to diminished intensity of the inflammatory 
action, a marked tendency to recurrence and persistence of the process, 
and a preponderance of scaling and infiltration as contrasted with the 
active secretion and crusting of acute phases. It is important, how- 
ever, to remember that chronic eczema is not only the frequent sequel 
of such acute phases, but is prone also to recurrent exacerbations of 
acute grade, during which the serous discharges, consequent crusts, and 
angry aspect of the affected surface do not fail to reappear. The itch- 
ing so characteristic of the malady in all its manifestations is often 
more annoying than in the acute phases of the disease. 

Chronic eczema may involve a limited region of the skin, or may 
invade the entire surface of the body from the head to the feet. Rarely 
thus generally developed, it is more frequently observed upon circum- 
scribed patches of the integument, as, for example, the scrotum or the 
flexor surface of a joint, in which situation it may linger for years or 
even for a lifetime, now better and now worse, or disappear for brief 
periods only to return with each recurrence of its cause. 

Etiology. — Eczema is a disease of both sexes and of all ages. Ten- 
dencies to all disorders of the body may be inherited, but eczema, as 
such, is not an inherited disease. No child was ever born into the 
world with an eczema. Certain individuals, however, show a peculiar 
susceptibility to eczema. In these persons the disease may occur with- 
out obvious cause, and is often produced by conditions, either internal 
or external, which are ineffective in the great majority of people. It 
is noted elsewhere that eczema in certain instances is due to parasites ; 
but for the majority of cases it should, nevertheless, be classed with 
non-contagious affections. 

In many cases no cause of eczema can be discovered beyond the 
causes which operate exclusively within the skin-organ and which are 

21 



322 INFLAMMATIONS. 

proper to itself. These causes are necessarily obscure, and will so 
remain until we are in possession of far more knowledge than possessed 
at present as to the complex and inscrutably delicate processes by which 
innervation, nutrition, and new formation of the living matter of the 
skin are both conserved and impaired. The autonomy of the integu- 
ment must be conceded to the extent recognized in other organs of the 
body. There are diseases of the liver that are referred neither to the 
blood, to the nerves, nor to the action of poisons. There are diseases 
of the heart that are induced by neither rheumatism nor syphilis. 
When the etiology of the disorders of all the viscera is perfected that 
of the skin displaying the lesions of eczema will assuredly be more 
distinct. 

These remarks are justified by clinical facts. Eczematous affections 
may occur in individuals who are in every respect superb examples of 
good health, and whose bodies, after the most thorough and careful 
examination, fail to reveal either an external or an internal cause for 
the disorder. It is true that in a majority of cases eczema is associ- 
ated with some disturbance of the general economy, but it occurs in 
persons who are affected with every form of bodily ailment, those 
suffering from acute and chronic disorders of every viscus and system 
of the body, and even those affected with other disorder^ of the skin. 

Just what influence these varied systemic disorders may have upon 
eczema is not known. For the present they should be considered for 
the most part as either coincidences or as conditions favoring the de- 
velopment of diseases in general, eczema not excepted. By interference 
either with innervation, nutrition, development, or excretion, or with 
the performance of other important functions of the body, as well as by 
local and reflex irritation of the surface, these internal causes operate 
by inviting, aggravating, or prolonging an eczematous attack. Among 
such predisposing conditions may be named not only diseases, but also 
physiological states, such as pregnancy, lactation, and dentition; oc- 
cupations necessitating inordinate fatigue of body or of mind, espe- 
cially with the exclusion of sunlight ; and lastly substances foreign 
to the body which produce an irritative action upon the mucous sur- 
faces, such as certain dietary and medicinal articles, intestinal par- 
asites, and instruments or fluids introduced into the mucous canals, as, 
for example, the male urethra. 

The systemic conditions which occur most frequently with eczema 
are those dependent upon defects in digestion, assimilation, and excre- 
tion, such as constipation, the various forms of indigestion, rheuma- 
tism, gout, and allied conditions. In individuals suffering from these 
disorders the secretions from an eczematous surface have been found 
to contain an excess of uric acid, or have dried to form a visible crys- 
talline deposit of urates on the surface. In these so-called " gouty 
eczemas" the disease commonly occurs independently of any recog- 
nized external cause, is symmetrical, recurrent, and it may be found 
in several members of a family or in successive generations. In 
some individuals, and frequently in children, certain articles of diet 
produce a dermatitis which persists and spreads as an eczema. Gly- 
cosuria and less frequently albuminuria may be discovered before or 



ECZEMA. 323 

after the appearance of an eczema. In the foregoing conditions, depend- 
ing upon some form or degree of malassimilation, it is probable that 
toxins or imperfectly metabolized food-products circulating in the blood 
act either directly upon the excretory glands or upon the nerve-end- 
ings of the skin, or indirectly through vasomotor disturbances, or 
through so-called "reflex irritation." That the nervous system is 
closely related, etiologically and pathologically, to some forms of 
eczema is now recognized by most observers. Eczema occurs in various 
organic and functional neuroses, in simple nervous exhaustion or debil- 
ity, in neuritis, neuralgia, or following injury to a nerve. It may even 
follow nervous shock. Through the action of the sympathetic and 
vasomotor nerves various organic diseases may cause an irritation or 
congestion of the skin, and thus contribute one or more factors to the 
production of an eczema. 

Eczema seems, in exceptional cases, to bear some relation to spas- 
modic asthma, either coexisting with that disease or its attacks regu- 
larly alternating with asthmatic paroxysms. This relation may be 
due to the exquisite sensitiveness of the skin, the mucous membranes, 
and the nervous system exhibited in some patients. 

Finally, ansemia, chlorosis, tuberculosis, scrofula, syphilis, or any 
other systemic disorder that lowers the general vitality and that of the 
skin, may favor the occurrence of eczema or of any other disease to 
which the skin may be exposed. 

The external causes of eczema are identical with those of dermatitis, 
and are chemical, mechanical, or thermal in their action. As stated 
on a preceding page, no sharp distinction can be drawn between 
eczema and any other dermatitis due to external causes, but those 
forms of dermatitis which persist after the removal of the external 
cause are probably due in part to, and are continued through, the 
action of other etiological factors, and are conveniently classed with 
eczema. It is doubtful if any of the local causes of dermatitis, acting 
for a limited period, could produce a persisting eczema without the 
cooperation of other conditions, either internal or external. The 
large majority of all externally operating causes of dermatitis fail to 
be effective in the mass of individuals. Even the poison-ivy, a fertile 
source of the disorder in susceptible individuals, will fail to influence 
others. The late Professor Boeck, of Christiania, when he last visited 
America, rubbed the leaves of this plant over his hands and face 
in repeated efforts to produce the disease, and failed of the desired end. 

Respecting the numerous agencies operating thus externally and 
capable of producing the disease under consideration, they can all be 
referred to either solar light and heat, to contact with foreign bodies 
in various fluid or solid states, to toxic agencies of a widely differing 
nature, to traumatisms in varying degrees, and to the action of para- 
sites. Many of these agencies cooperate, some include others, and 
some become effective by aggravating a disease which others have 
engendered. The reader is referred to the chapters on General Etiol- 
ogy and Dermatitis for fuller consideration of this subject. It will be 
sufficient to note here that acids, alkalies, antimonial and mercurial 
compounds, mustard, sulphur, castor-oil, capsicum, arnica, turpentine, 



324 INFLA MM A TIONS. 

chloroform, ether, alcohol, and a long list of other medicaments are 
capable of producing eczema when applied to the skin. The same 
statement is true of articles manipulated in many of the trades — 
those, for example, handled by the grocer, the baker, the confec- 
tioner, the seamstress, the ink-manufacturer, the mason, the cook, 
the gardener, the laundress, the painter, the dyer, the printer, the 
tobacconist, and the chemist. Then, too, the eczema of the person 
exposed to severe cold, or to intense solar light and heat aided by 
reflection from water, or even to excessive artificial heat, as the fire of 
a furnace, illustrates the action of other causes named. Pressure- and 
friction-eifects are exhibited in the eczema produced by contact with 
gaiters, the edges of cuffs, trusses, crutches, and corsets. 

Scratching is a fruitful cause of eczema when the skin is affected 
with pruritus as a distinct disease or as a symptom of other cutaneous 
disorders. Thus, it is efficient in urticaria, scabies, and the prurigo 
of Hebra ; in the skin bitten by lice, insects, bedbugs, and fleas (which 
even without such interference are capable in many cases of inducing 
the disorder) ; and in the lower extremities when the skin of this region 
is distended by varicose veins. 

Water is capable of exercising an injurious effect upon the skin to 
the extent of producing an eczema whether it proceeds from the sudo- 
riparous glands in an excessive exudation of sweat, which is not duly 
removed by ablution, or is applied externally as a fluid in excessively 
cold or hot temperatures, or in the vapors of the popular Turkish and 
Russian baths or, yet again, be rendered irritating by saline or other 
constituents. 

The causes are at times climatic, the disease being worse in most 
people during the cold seasons. Cold winds and sudden temperature- 
changes, especially from warm to cold, will often aggravate and pro- 
long an existing eczema. 

The external sources of eczematous trouble named above should be 
regarded simply as suggestive illustrations. It should be borne in 
mind that every contact with the external world sufficiently severe or 
prolonged to awaken the resentment of the healthy skin may be fol- 
lowed by the protest of the latter in the shape of an eczema ; and the 
same may be true when even the most trivial external accidents occur 
to the sensitive skin of certain individuals especially prone to the 
disease. 

That many eczemas are modified in their course, if not indeed 
caused wholly or in part, by various micro-organisms is undoubtedly 
true. Aside from pus-cocci found in pustular eczema, however, no 
definite parasites have yet been demonstrated to be effective either in 
the production or in the modification of eczema. The healthy skin is 
the habitat of many forms of parasites, chiefly vegetable, and every 
skin-lesion is open to infection with any one of the many micro-organ- 
isms with which it may come in contact ; hence, it is probable that the 
disease, once begun, is modified by secondary infections of one kind or 
another. Secondary pus-infection is frequently recognized, and the 
manner in which some forms of eczema respond to antiparasitic treat- 
ment leads to the inference that some of the many micro-organisms 



ECZEMA. 325 

found in the lesions are active in the prolongation, if not in the produc- 
tion, of the disease. Numerous parasites, including the morococcus of 
Unna, have been cultivated and described as the cause of eczema, but 
their etiological relations to the disease have not been demonstrated 
satisfactorily. 1 

Pathology. — The pathological changes in eczema are those of inflam- 
mation of the skin, varying somewhat with the acuteness or chronicity 
of the process, and with the character and career of the exudate fur- 
nished in each expression of the disease. In most cases there is, first. 
a circumscribed or diffused hyperemia of the affected part followed by 
dilatation and congestion of the blood-vessels of the corium, exudation 
of serum, diapedesis of white blood-corpuscles, and oedema. 

The process probably begins in the papillary layer, from which it 
extends to the epidermis, to the deeper parts of the corium, and in 
exceptional cases inward even to the subcutaneous tissue. The oedema- 
tous infiltration may be quite extensive, producing marked swelling 
over considerable areas, or it may be slight and circumscribed. At 
times it appears- only about the hair-follicles, producing perifollic- 
ular papules. The cell-infiltration about the vessels of the corium is 
formed in part of leucocytes, some of which wander outward into 
the rete, but is probably composed largely of young connective-tissue 
cells. 

The epithelial changes in eczema vary greatly with the stage, in- 
tensity, and type of the disease. It is not determined definitely if 
these changes are always dependent upon and follow the conditions 
described above in the corium, or if they are usually, or even rarely, 
primary in origin. It is probable that they are secondary to the vascu- 
lar changes in the corium, though some observers, including Unna and 
Leloir, believe that in most cases the epithelium is first affected. In 
practically all forms of eczema there is a parenchymatous oedema of the 
epithelial cells, especially of the transitional layers, as a result of which 
there is imperfect keratinization (parakeratosis) of the horny layers, the 
cells of which contain some moisture, retain imperfect nuclei, and are 
exfoliated in scales. In acute erythematous eczema running a brief 
course the epithelial changes may be limited to this parakeratosis, but 
in most cases they are followed by vesicle-formation in the upper part 
of the rete. The manner in which vesicles are formed is a matter of 
dispute. The first vesicles of acute eczema are apparently due to the 
formation in a number of contiguous cells of a clear space between the 
nucleus and the protoplasm, which enlarges until there is left merely a 
mesh work filled at first with serum, and later with serum, fibrin, and 
cellular fragments. If these spaces become filled with leucocytes as a 
result of more active degeneration of the cell-substance, or possibly as 
a result of secondary infection, they become pustules, the contents of 
which dry on the surface, forming thick crusts. In very acute cases, 

1 For a full discussion of the parasitic and other causes of eczema the reader should 
consult the Transactions of the Fourth International Congress of Dermatology, Paris, 
August 2 to 9, 1900; also papers bv Morris, Brit. Jour, of Derm., October, 1898; 
Koberts, Ibid., 1899, pp. 7 and 6Q ; Torok, Annal. de Derm, et de Svph., 1898, p. 1073, 
and 1899, pp. 30 and 37 ; Sabouraud, Ibid., 1899, p. 305 ; Leredde, Ibid., 1899, p. 438 ; 
Kromayer, Arch. f. Derm. u. Syph., July, 1900 ; and Kaposi, Ibid., October, 1900. 



326 INFLAMMATIONS. 

with an abundant exudate, the horny layer may be raised from the rete 
to form vesicles or bullae. According to Unna, vesicles in the later 
stages of eczema are due solely to an intercellular oedema. 

In eczema rubrum the horny layer is raised from the rete and de- 
stroyed without true vesicle-formation. The rete is thus exposed 
directly to the air, Or is partly covered by an amorphous coating of 
dried serum and degenerated cells. 

In the later stages of eczema there is more or less hypertrophy of 
the rete (Unna's acanthosis), with corresponding enlargement of the 
papillae, forming papules and elevated, thickened areas. In chronic 
cases the cell-infiltration and proliferation in the corium become very 
conspicuous, producing the thickening of the skin so characteristic of 
patches of chronic eczema. In these cases the papillae are larger than 
normal, and the vessels of the corium are dilated and surrounded by con- 
nective-tissue cells. The process may extend to the subcutaneous fatty 
layer, which then loses much of its fat, and becomes dense and attached 
to the skin. Hypertrophy of connective tissue and lymphatic obstruc- 
tion with elephantiasic changes may follow. In these cases the sebaceous 
and coil-glands and the hair-follicles may be partially or entirely 
destroyed by undergoing degeneration and atrophy. 

The fluid exuded in eczema, in vesiculation, or in a free discharge 
from the surface, is always characteristic. Though in the earliest 
vesicles it is a simple blood-serum, it soon becomes a yellowish-white, 
sticky, and syrupy liquid, feebly alkaline in reaction and depositing 
albumin in abundance when treated with heat and nitric acid. Exposed 
to the air, it desiccates in light-yellowish to brownish friable crusts 
resembling honey or gum. 

Increase in the pigment-particles distributed to the epithelia of the 
rete is characteristic of the chronic forms of eczema, and more espe- 
cially of those in which the circulation is somewhat impeded by the 
influence of gravity, as, for example, in the lower extremities. This 
increased pigmentation is true, however, of all diseases accompanied by 
an augmented afflux of blood to any part of the body, as, for example, 
over the surfaces of joints to which for many years stimulating embro- 
cations have been applied. 

The elevation of the body-temperature in the inflamed skin is some- 
what proportioned to the rapidity of the process. In acute eczema 
such elevation may exceed 105.5° F. (41° C), while in chronic eczema 
it can scarcely be appreciated. 

The subjective sensations in eczema are due, undoubtedly, to an 
irritation of the nerve-endings in the corium and rete. It is not known 
if this nerve-irritation is secondary to other pathological changes in the 
skin, or if the nerves are primarily active in disturbing the nutrition 
and function of other tissues. 

Diagnosis. — Though of a dozen consecutive cases of eczema no two 
may look alike, yet they all have some characteristics in common and 
the diagnosis is usually attended with little difficulty. Eczema in 
its manifestations is such a protean disease and is, moreover, of such 
frequent occurrence, that it is necessary to establish a differential diag- 
nosis between it and a large number of other cutaneous disorders. The 



ECZEMA. 327 

more important of these disorders are named below in alphabetical 
order for convenience of reference, the distinctive peculiarities of each 
being briefly appended. In making a diagnosis it must be remembered 
that eczema may coexist with any other disease of the skin, and that 
it very frequently thus complicates such cutaneous disorders as sebor- 
rhea, psoriasis, and scabies. 

Acne. — Acne occurs chiefly on the face, the neck, and the back of 
the trunk, and its pustular forms may be mistaken for eczema of the 
same localities ; but pustular acne is usually accompanied by a deeper- 
seated infiltration than the similar lesions of eczema, and this infiltra- 
tion is also generally limited to the sebaceous glands or the periglan- 
dular tissue. In eczema the itching is often severe, while in acne the 
subjective sensations are those of heat or burning. Comedones inter- 
mingled with the pustules of acne will aid in distinguishing the two. 

Erythematous eczema of the face is to be distinguished from Acxe 
Rosacea by the more generalized infiltration of the former, its produc- 
tion of itching, and its greater diffusion over the face ; while acne 
rosacea is limited more often to the cheeks, nose, and brow, and to the 
region adjacent to these parts. The patch of erythematous eczema is 
" hot," that of acne rosacea is cold, to the touch. The former is seen 
in infancy, the latter is rare in that period of life. Acne rosacea in 
many cases is distinguished readily by the development of visible 
blood-vessels in the skin of the cheeks or the nasal region. Lastly, in 
erythematous eczema the eyelids may suffer, while in acne rosacea this 
is the exception. In severe forms of acne the subepidermic pus-form- 
ation and the resulting scar will prove significant. 

Dermatitis. — Dermatitis of artificial origin is to be distinguished 
from idiopathic eczema rather by its history than by special differences 
in the appearance or evolution of the lesions. In many cases the two 
affections are indistinguishable. A history of traumatism or of the 
external application of irritant or of toxic articles will often serve to 
distinguish the two. When the dermatitis has been produced by an 
externally applied irritant the resulting inflammation of the skin will 
often exactly outline the area of contact. Dermatitis of artificial pro- 
duction is usually sudden in its onset, the date of which will nearly 
correspond with the time of operation of an exciting cause. The sub- 
sidence of the symptoms after the withdrawal of the cause will also 
point to the nature of the affection. Eczema is also much more capri- 
cious in its distribution and career than dermatitis. 

Erysipelas. — Erysipelas is generally accompanied by febrile symp- 
toms ; in many cases bulla? appear. The affected surface is reddened, 
much more swollen than in eczema, owing to the involvement of deeper 
tissues, and it exhibits besides a characteristic shining appearance, 
which is always absent in erythematous eczema. The line of demar- 
cation between the affected and unaffected portions of the skin is 
usually distinctly defined in erysipelas, ill defined in eczema. Erysipelas 
is an exceedingly acute affection and spreads from one point to another 
with a rapidity that is never noticed in eczema ; the latter disease, 
moreover, usually exhibits under a lens its minute papules or vesicles. 
In eczema also, when occurring upon the face in the erythematous 



328 INFLAMMATIONS. 

form, the scalp is usually spared, while erysipelas tends to invade the 
scalp and the regions covered by the beard. 

Erythema. — Eczema is to be distinguished from the forms of 
erythema which are due to hyperemia only, by the presence of an 
inflammatory process. The erythema simplex which advances to exu- 
dation at once transgresses the artificial line of distinction between 
the purely congestive and the purely exudative disorders. It must, 
therefore, be remembered that many eczemas begin as erythemata, and 
that clinically the latter may represent but a stage in the morbid 
process. The discharge in erythema intertrigo results from imprisoned 
or from chemically altered sweat, and will not stiffen linen as does 
the serous exudation of vesicular eczema, for example. Erythema 
multiforme, an affection really on the border-line between the two 
pathological classes here sought to be distinguished, will be recognized 
by the absence of severe itching and the recurrence of the disorder 
at certain special seasons of the year ; while Erythema papulosum, E. 
tuberosum, and E, nodosum display solid elevations of the skin-sur- 
face much exceeding in size the minute lesions of papular eczema. 

Herpes. — Eczema is so associated with the occurrence of a vesicle in 
the minds of many that other vesicular disorders are likely to be con- 
founded with it. But in herpes febrilis the vesicles are usually grouped 
about the mucous outlets of the body, and when actually under observa- 
tion they exceed in size the minute and transitory lesions of vesicular 
eczema. In herpes zoster, with the limitation of the eruption in the 
course of a nerve to one side of the body and the production of grouped 
vesicles of a larger size and more persistent type, there is commonly a 
history of precedent or coincident neuralgic pain. The subjective sen- 
sation in the skin is a decided burning rather than itching, and there is 
a possibility of the subsequent production of scars. 

Impetigo. — In these forms of disease pustular lesions are usually 
isolated, do not spring from an infiltrated surface on which other lesions 
may be visible, and are unaccompanied by the intense pruritus which 
is characteristic of eczema. The pustules, moreover, are larger, and 
the resulting crusts, as a rule, are bulkier and darker colored than 
those in eczema. Again, in pustular eczema the cutaneous affection 
usually occurs in one or more patches, while in impetigo a dozen or 
more isolated pustules may be irregularly scattered over the entire 
surface of the body. In impetigo there may be a history of extension 
of the disease from one member of a family to another. 

Lichen Planus. — Papular eczema may be confounded with lichen 
planus, but in the latter disease the typical papule has an irregular or 
polygonal base ; a flat or umbilicated apex, which is covered with a thin, 
closely adherent, varnished-looking scale; and a violaceous or dull- 
crimson hue. The papules of eczema have round or oval bases, acu- 
minate or rounded summits, and are brighter red in color. They also 
form more rapidly and undergo change of type more frequently than 
the more persistent papules of lichen planus. The patches of lichen 
planus are more sharply defined than those of eczema, and are usually 
angular or linear in outline. The lesions of lichen planus on disap- 
pearing leave a characteristic brown or sepia-tinted pigmentation. 



ECZEMA. 329 

Lupus Erythematosus. — Lupus erythematosus greatly resembles cer- 
tain forms of squamous eczema. The great chronicity of lupus ; the 
firm attachment of the scales ; the symmetrical distribution of many 
patches upon the face; the association of some forms of the disease with 
the sebaceous glands ; the definite border of each involved area ; and, 
above all, the discovery of a cicatrix left by the morbid processes will 
sufficiently distinguish the disorder. In eczema there are usually itch- 
ing, often vesiculation, more rapid extension of the borders of a single 
patch, and scales much more loosely attached than in erythematous lupus. 
The scales of eczema are never provided, as in lupus erythematosus, 
with stalactitiform plugs on the inferior surface. 

Mycosis Fungoi'des. — Mycosis fungoi'des, in its earliest stages, may 
be indistinguishable clinically from some forms of localized or even 
generalized eczema. As a rule, however, the early erythematous and 
eczematoid lesions of mycosis fungoides can be recognized by their 
characteristic gyrate outlines, assuming, as they do, the shape of a 
kidney, horseshoe, half-moon, and other fantastic, more or less circinate, 
forms. These figures may change frequently in form and location, or 
may disappear spontaneously, to return in the same or in new sites. 
They differ further from eczema in being located on any or every part 
of the body, independently of external influences, and in failing to 
respond to treatment during months or years. After the formation of 
characteristic thickened and elevated plaques the diagnosis is not 
difficult. 

Lupus Vulgaris. — Lupus vulgaris is readily distinguished from eczema 
by its more chronic career, by its larger papules and tubercles of dark 
reddish-broAvn hue, and by every one of its destructive processes, none 
of which is ever recognized in eczema. 

Pediculosis. — As eczema is often induced by lice upon the head, the 
pubes, or the clothing, it is always necessary to exclude the operation 
of such causes for both diagnostic and therapeutic purposes. Eczema 
limited to the pubic region or to the pubic and axillary regions should 
suggest careful examination of the skin and the hairs for the discovery 
of the crab-louse. As for the pediculus corporis, it should be the rule 
of the physician, invariable and never to be forgotten (whatever the 
social position or refinement of his patient), to search in a suspected 
case for evidence of the parasite upon the under surface of the clothing 
worn next the skin, at the instant of its removal and while the patient 
supposes him to be busied with the inspection of the cutaneous lesions. 
The excoriations produced by scratching wounds inflicted by body- 
lice are usually out of all proportion to the amount of skin-disease 
present; and this excoriation is the most significant of all symptoms 
next to the discovery of the corpus delicti. Head-lice may precede or 
may follow eczema of the scalp, but either they or their ova (nits), 
clinging in numbers to the hairs, will be visible to him who looks 
carefully for them. 

Pemphigus and Pityriasis Rubra. — The large isolated bullae of pem- 
phigus vulgaris are never seen in eczema. In pemphigus foliaceus 
the lesions are succeeded by the formation of pastry-like crusts, serous 
exudation, considerable soreness, and the eventual production of an 



330 INFLAMMATIONS. 

extensive and usually fatal exfoliative dermatitis. Marasmus gradually 
or in some cases rapidly ensues, while, as a rule, itching and infiltration 
are not present. The disease known as pityriasis rubra is equally rare 
and fatal, and, though unattended with the production of bulla?, is char- 
acterized by an abundant epidermic exfoliation ; itching and infiltration 
being either entirely wanting or insignificant in comparison with the 
other symptoms present. The scales, too, are papery, large, and thin ; 
there is no vesiculation and moisture, and little, if any, infiltration of 
the skin. The integument is, moreover, of a uniformly reddish hue. 
Both pemphigus foliaceus and pityriasis rubra are particularly liable 
to be complicated with chills or with uncontrollable diarrhoea. With- 
out question, many of the reported cases of so-called " pityriasis rubra " 
are instances of squamous eczema or of simple exfoliative dermatitis. 
Here the localization of the disease to one or more patches upon the 
body, the severe itching, and the distinct infiltration of the patch point 
to the eczematous character of the disease. Observation of such patients 
will finally convince the physician, in many cases, that there is occa- 
sional weeping from the surface. 

Pityriasis Rubra Pilaris. — Often this disease resembles in a high 
degree, and it may indeed be confused with, the squamous forms of 
eczema. In general there are not found in eczema characteristic 
lichenoid papules formed about the hair-follicles, with their hyper- 
keratinized cap sheathing the follicular orifice. Nor is the selection 
of the extremities, and especially the dorsal aspect of the fingers, char- 
acteristic of eczema. In eczema there are usually distinct marks of 
scratching that may wholly be wanting in pityriasis rubra pilaris; and 
the latter has in most cases a more chronic course. 

Prurigo. — In the prurigo of Hebra, a disease exceedingly rare in 
America, there are infiltration, intense itching, and numerous minute 
and larger papules. But this disease usually occurs within a year or 
two after birth and lasts for a lifetime, extending generally over the 
greater part of the body, sparing only the palms and soles (which 
eczema does not), and is accompanied by inguinal adenopathy. 

Pruritus. — In pruritus, often confounded with prurigo, there is itch- 
ing without lesion of the skin save that induced by the nails to relieve 
the sensation. Hence, pruritus without scratching will not reveal a 
cutaneous disease, while pruritus with scratching will exhibit either 
excoriations or an eczema induced by the attacks made upon the skin. 
The latter condition, however, is rarely noted. The distinction will 
be clear when it is remembered, first, that pruritus is usually of a 
paroxysmal character, being worse regularly at certain hours or seasons; 
second, that pruritus not originating in a cutaneous lesion, but indirectly 
producing the latter by the medium of the finger-nails, never exhibits 
as much cutaneous excoriation as the skin bitten by lice or attacked 
with eczema. The impressive features here are always the dispropor- 
tion between the complaint of the patient and the visible symptoms, 
and the vast preponderance of all lesions in those regions of the body 
most accessible to the hands, such as the anterior faces of the limbs, 
the genital region, the lower belly, etc. 

Psoriasis. — Psoriasis and eczema in typical forms are distinct. 



ECZEMA. 331 

Variations in type from one to the other furnish many obscure 
cases. 

The following are the chief diagnostic points in -psoriasis: sharp 
definition of contour of patch; abundance and lustrous hue of the 
scales; absence of moisture; vascularity of tissue beneath the scales; 
sites of election on posterior aspect of the trunk and extensor surfaces 
of limbs; chronicity in course; uniformity of lesions; and usually 
absence of itching. In eczema there are an ill-defined contour ; usually 
scanty scales not having a nacreous hue; a preference for the flexor 
surfaces of the extremities, though the disease may occur in any por- 
tion of the body; generally, at some period in its course, a history of 
moisture; polymorphism, as regards lesions; and a marked intensity 
of subjective sensations. Upon the scalp psoriasis is prone to extend 
beyond the hairy border in a fillet stretching across the upper portion 
of the forehead, thence irregularly down in front of the ears; while 
eczema of the face, when the scalp is also invaded, departs boldly from 
the hairy parts to the lower forehead, the lips, nose, cheeks, or chin, 
regions which are relatively spared by psoriasis. Finally, the two 
diseases, in doubtful cases, will generally be distinguished by carefully 
searching the entire surface of the body, upon some part of which in 
psoriasis there will usually be discovered a tell-tale patch of typical 
appearance. 

Scabies. — Scabies is really an artificial eczema induced by the incur- 
sions of the acarus scabiei, and its lesions are thus those of eczema. In 
scabies, however, the pruritus is intense and the recently formed 
papules, vesicles, and pustules are more distinct and isolated than in 
eczema. The discovery of the presence of the parasite, especially if 
there be a history of contagion, and the localization of the disease in its 
sites of preference, will at once determine the diagnosis. Scabies never 
attacks the scalp. Its sites of preference are in both sexes the fingers, 
hands, wrists, and axillae; in women the breast and the nipple; in men 
the penis; and in children the buttocks. The presence of the acarian 
furrow, if the disease has existed for some time, and the appearance 
of minute blackish dots or points upon or about the lesions, usually 
suffice to establish the nature of the disease. 

Seborrhcea. — Seborrhcea and eczema may coexist, either disease pre- 
ceding the other. Typical forms of each are readily distinguished. 
In eczema there are infiltration and much consequent itching; in seb- 
orrhcea there is neither. The scales of seborrhcea are more voluminous 
and greasy than those of eczema, are freely shed from the surface, and 
are seated usually upon an integument of scarcely altered hue; in 
eczema the scales are dry, scanty, and more firmly attached to an 
hypersemic base. Seborrhcea of the hairy parts is generally symmet- 
rically diffused; eczema, though occurring with ill-defined contour, is 
rarely as symmetrical, usually more acute, and is seldom followed by 
alopecia. Upon non-hairy portions of the body the same distinctions 
can to a great extent be observed. The crusts of eczema removed from 
the face generally disclose beneath them an oozing surface, while the 
under surface of these crusts never exhibits the stalactite-like prolonga- 
tions which pass from the under surface of seborrhcelc crusts into the 



332 INFLAMMATIONS. 

patulous orifices of the excretory ducts of the sebaceous glauds. In 
eczema seborrhoei'cum the features of both diseases are almost com- 
pletely fused. 

Sycosis. — Both the hyphogenous and the coccogenous forms of 
sycosis are limited to the region of the beard, while eczema of 
the hairy portions of the face will usually be found to affect other 
parts. In eczema the itching is severe, the exudation spreads beyond 
the limits of the beard, and the discharge is characteristic ; while in 
both forms of sycosis there is less oozing and the subjective symptoms 
are trivial. The discovery of the parasite in the root or the shaft of 
the hair will at once distinguish the hyphogenous forms of the disease. 
In coccogenous sycosis each pustule is perforated by a hair. Eczema 
limited to the region of the beard is even rarer than the two varieties 
of sycosis. The circumscribed indurations and tuberculations of the 
affection produced by the trichophytons, as well as the loosening of the 
hairs in their follicles, constitute further distinctive differences. 

Syphilis. — Several syphilitic eruptions resemble certain forms of 
eczema. In the eruptions due to syphilis, however, there is usually a 
history of infection ; of involvement of the glands and mucous surfaces ; 
of ulceration and cicatrices in advanced periods, and, especially in the 
case of infants with an eczema-like eruption, of a history of snuffles. 
The intense itching of eczema is characteristic of no one of the syphil- 
ides, and the latter are remarkable for their tendency to occur with a 
circular or partially circular outline, and to be covered with bulky mal- 
odorous crusts. A point worthy of note is that compared with chronic 
eczematous affections a syphilitic eruption limited for an equal period 
of time to one locality will often ulcerate or exhibit evidences of repair 
by scar-tissue, no such results occurring in eczema. 

Syphilis of the palms and soles exhibits very distinct outlines in 
the usually circular, circumscribed, and deeply infiltrated patches 
present, which are often symmetrical in development, or are at least 
situated on both sides of the body even if more fully developed 
upon one limb. Syphilitic pustules upon the scalp usually rise above 
superficial but well-defined ulcers. Syphilitic eruptions encircling the 
mouth in children are less angry-looking and formidable than those of 
severe eczema of the same region, being often made up of flattened pap- 
ules, moist or scaling, grouped in circles about the lips, with mucous 
patches at the angles. 

Tinea Circinata. — In ringworm there should be a history of con- 
tagion, microscopical discovery of the vegetable parasite, distinct con- 
tour of all separate patches, and absence of marked subjective sensa- 
tions and of discharge. These symptoms are not those of eczema. In 
ringworm of the scalp the hairs loosened in their follicles are usually 
either brittle or are actually broken at a short distance from the scalp ; 
the scales are fine, dirty white, and not torn from the surface by the 
finger-nails. In eczema the hairs are unaffected, and their extraction 
is productive of pain. In ringworm of the body the patches are dis- 
tinctly circular, are more scaly or papular at periphery than centre, 
and, moreover, yield with promptness to the action of a parasiticide. 
Occurring about the thighs and anogenital region, the disease may be 



ECZEMA. 333 

complicated by eczema, but the characteristic " festooning " of the 
advancing border of the patch downward along the thigh, or upward 
over the pubes, will suggest a microscopical examination of the scales 
scraped from the surface. 

Tinea Favosa. — The large, friable, dirty crusts of an old and 
neglected favus of the scalp might be mistaken for the crusts of 
eczema of the same part ; but here the exudation is slight, and there is 
little scratching, as in eczema, hence no history of discharge. The odor, 
moreover, is characteristic. In case of uncertainty a careful search 
would reveal a few characteristic cup-shaped and yellow crusts, or the 
microscope would demonstrate the parasitic nature of the disorder. 

Tinea Versicolor. — In this disease, also, the microscope will re- 
veal, beneath the epidermal plates, the spores and filaments of the 
fungus which produces the ailment. From eczema the disease is 
easily distinguished by the absence of infiltration and of any history 
of inflammation ; by the very slight subjective sensation it produces ; 
by its peculiar fawn- to chocolate-colored, slightly yellowish patches, 
which are covered with superficial furfuraceous scales, are limited to the 
covered parts of the body and often to the anterior surface of the trunk, 
and are readily removed by the action of a parasiticide. 

Urticaria. — In papular forms of the disease there may be a re- 
semblance to eczema. This resemblance is more marked in children, 
as here the two diseases may be intermingled. Characteristic wheals 
often occur by the side of eczematous patches, but, as a rule, urticarial 
lesions are less grouped, more generally disseminated, more evanescent, 
and much less scratched. 

Treatment. — The treatment of eczema usually presents a complicated 
problem. The causes of the disease are numerous, frequently obscure, 
and when discovered are often difficult to remove. Eczema shows 
little tendency to spontaneous recovery, but tends rather to persist, to 
spread to contiguous or distant parts of the body, and to recur. Al- 
though many cases of the disease respond well to local treatment alone 
if the affected surface can be given absolute rest and kept constantly 
covered with the desired dressing, such ideal treatment can rarely be 
carried out except in hospital-patients. Moreover, in many cases of 
eczema the general health of the patient must be improved before local 
treatment can be effective. The nutrition and functional activity of 
the skin depend largely upon the condition of the general system, for 
the skin is but one of many organs in a complex organism. It follows 
also that every serious disease of the skin must interfere more or less 
with the general health. The fear that too rapid a cure of eczema may 
result in disease of deeper-seated organs is baseless. The sudden 
improvement or disappearance of an acute eczema coincidently with the 
development of a pneumonia or other grave disorder may be explained 
by the rapid withdrawal of a large amount of blood from the skin- 
surface to the newly congested organ. The improvement in the eczema 
is thus a result and not a cause of the deeper-seated disease. 

The treatment of eczema requires both local and constitutional 
management. 



334 INFLAMMATIONS. 

(A) Constitutional Treatment. — In many cases internal treatment 
may be wholly ignored, and eczema be successfully controlled by local 
measures alone, even though there be coincident systemic disease. 
Often, however, the eczema is an external expression or result of other 
pathological conditions which must be removed before the eczema can 
be permanently cured. These systemic disorders vary widely, ranging 
through the whole field of internal medicine, including hygiene. In 
these pages a few suggestions only can be given regarding the internal 
treatment of eczema, much being left to the practitioner's knowledge 
of general medicine. It is often necessary not only to relieve disease 
of other organs, but also to study the patient's temperament, habits of 
eating, drinking, bathing, sleeping, etc., before an obscure cause of a 
stubborn eczema can be found and removed. 

Diet. — No absolute rule can be laid down regarding the diet in 
eczema. Each individual should be given the quantity and quality of 
food that will best nourish his body without interfering with digestion 
and elimination. The ansemic, strumous, and poorly nourished subject 
should be given sufficient fresh beef, mutton, eggs, milk, cream, vege- 
tables, and other nourishing foods. Cod-liver oil, butter, and other 
fats, when easily digested, are of special value, as also are the various 
malt-preparations, particularly when digestion of the carbohydrates is 
at fault. In the plethoric, the overfed, the gouty, and in those suf- 
fering from faulty digestion and elimination, a diet restricted to the 
lowest point consistent with the health of the individual is often of the 
greatest importance. In these cases excellent results are obtained by 
limiting the patient to a diet of bread and milk, or of milk alone, or of 
milk and seltzer-water, for several weeks. In general, the diet allowed 
the eczematous patient should be limited to the most digestible articles 
of food, and should exclude those (a list of which is given in the 
chapter on Urticaria) capable of exciting cutaneous irritation. Cooked 
vegetables, fruits, and a small quantity of fresh meats may be per- 
mitted ; but starchy articles in excess, hot breads and cakes, pastry, 
confectionery, cheese, pickles and pickled meats, cucumbers, cabbage 
(both raw and cooked), parsnips, turnips, beans, oatmeal, cracked 
wheat, pease, celery, shell-fish, salted fish and meats, pork, and veal 
should be avoided. Milk, when not the source of constipation, may 
be drunk, but not during the meal-hour. Coffee, tea, and cocoa are in 
the doubtful list, as they are positively injurious to some patients and 
apparently without effect in others. Tobacco should always be for- 
bidden to male patients suffering from a serious eczematous attack. 
Alcohol in every form is contraindicated save in condition of debility, 
or in case of its previous habitual use in moderation by persons of 
advanced years. In gouty patients the dietary should be of the 
strictest appropriate to that condition, and in diabetic eczema the regi- 
men proper in glycosuria is observed with great benefit in most cases. 

Internal Medication. — There are no specifics for eczema. Such 
remedies only should be given as are indicated by the general condi- 
tion of the individual. Over-medication and uucalled-for dosing 
with " blood " medicines is a common error in the management of this 
disease. The number of patients presenting themselves for treatment 



ECZEMA. 335 

of eczema, both in dispensaries and hospitals and in private practice, 
who have aggravated their condition by medicaments they have swal- 
lowed is incredibly large. Men and women, infants and adults, those 
who have been under the charge of physicians, and those who have 
purchased drugs of an apothecary at the suggestion of the latter or 
of their friends, exhibit patches of acute or of chronic eczema aggra- 
vated by the injudicious use of arsenic, potassium iodide, potassium 
bromide, Donovan's solution, and other harmful preparations con- 
tained in the various " blood-purifying " remedies sold m the shops. 
The practitioner whose patient comes to him after making trial of any 
such remedies is strongly urged to set aside the operation of such mis- 
chievous agents, and to watch the eruption carefully Avhile their effect 
is vanishing. The result is often marvellous. The chief object of the 
constitutional, and also of the local, treatment of eczema is to remove 
all sources of irritation to the inflamed skin. 

An attempt to relieve pruritus by the use of anodynes internally 
is rarely necessary, and usually aggravates the disorder. Opium and 

I its preparations increase the pruritus, though in full doses they relieve 
temporarily. With some patients, and especially children, full doses 

I of quinine may relieve itching. Less frequently full doses of calcium 
chloride, largely diluted with water, may serve the same purpose. In 
an emergency, chloral, phenacetin, sulphonal, or even the bromides, 
may be given, but it must be remembered that, like opium, they are all 
liable to aggravate the pruritus after the first anodyne effect has passed. 
In the management of acute eczema cooling draughts are useful ; 
and in all cases occurring in patients who are plethoric, who are con- 
stipated, or who suffer from other symptoms of imperfect excretion, 
aperients and cathartics are needed. Often a brisk mercurial purga- 
tive in the form of blue mass or the compound cathartic pill may be 

i ordered at the outset. Five grains of blue mass or three grains of 
calomel may be given each night, followed by a saline laxative in the 
morning, for ten clays or two weeks. A tenth of a grain of calomel 
combined with sodium bicarbonate may be given every half hour for 
a day or two, and then three or four times daily for two weeks or 
longer, if at the same time salines are used to keep the bowels freely 
open. The rhubarb-and-soda mixture answers well in some cases. 
Podophyllin, or the familiar combination, nux vomica, aloes, and bella- 
donna, may be substituted for these articles. The saline cathartics, 
whether employed in medicinal formulae or in natural mineral waters, 
such as the Hathorn, Carlsbad, Hunyadi Janos, or Friedrichshall, are 
exceedingly useful in the management of most cases. The following 

; is a valuable combination often advised for cases in which both iron 
and magnesium sulphate are indicated: 

R 

Acid, sulphur, dil., f3u; 8 

6Q 



Magnes. sulphat., 


lij; 


60 


Acid, sulphur, dil., 


f#j; 


8 


Ferri sulph., 


Bss; 




Sodii chlorid., 


3j; 


4 


Cardamom, tinct. comp., 


f3j; 


4 


Aq. dest., 


ad Oss ; 


240 



M. 

Filtra. Sig. A tablespoonful before breakfast in a tumblerful of cool or of hot 
water. 



336 INFLAMMATIONS. 

An excellent remedy for some cases is from 15 to 20 drops of a fluid 
containing 2 parts of the fluid extract of cascara sagrada to 1 part 
each of glycerin and tincture of aloes, the dose to be taken at bedtime 
or before breakfast in a small glassful of water. A full dose of castor- 
oil on retiring is an excellent remedy in many neurotic cases, and may 
be continued for weeks if needed. 

In some cases of renal derangement the alkaline diuretics are indi- 
cated, such as potassium acetate, carbonate, or citrate, administered 
with nitre, squills, caffein, or lithium benzoate in from 3 to 5 grain 
(0.26-0.33) doses before meals, and in gouty cases colchicum, Vichy 
water, etc. Distilled or other pure water, or in suitable cases the 
alkaline spring-waters, taken in large quantities before meals and 
between meals, are very valuable as diuretics and as a means of encour- 
aging elimination. In patients suffering from acid dyspepsia liquor 
potassse, sodium bicarbonate, or ammonium carbonate may be required. 
Salol and other intestinal antiseptics are often of value. 

Aloes and iron, or aloes and ergot, are indicated in special cases. 
Where diuretics and alkalies are both indicated the following formula 
is often of service : 

R Magnes. sulphat., 
Magnes. carbonat., 
Colchici tinct., 
Menth. pip. ol., 
Aq. dest., 
Sig. Two tablespoonfuls in a wineglassful of water every three or four hours. 

Cod-liver oil is indicated in all cases of struma and tuberculosis ; 
calcium phosphate in bronchitis ; iron in anaemia and chlorosis ; strych- 
nine, hypophosphites, and other nerve-tonics in neurotic cases. 

In fleshy children affected with eczema capitis calomel internally is 
a valuable remedy, from \ grain to 2 grains (0.03-0.133) of calomel, 
with 2 to 3 (0.13-0.20) of rhubarb, rubbed up with 5 (0.33), of cal- 
cined magnesia, may be given once in a day to an infant; or -^V of a 
grain (0.003) of calomel, rubbed up with sugar of milk, may be given, 
three times daily, for ten or twelve days. Small doses of the un spiced 
syrup of rhubarb, with or without magnesia, may be required for the 
constipation of infants, or from 1 to 3 drachms (4.-12.) each of pow- 
dered rhubarb and sodium bicarbonate in 4 ounces (120.) of pepper- 
mint-water, of which a teaspoonful may be administered two or three 
times or oftener daily. Quinine, strychnine, syrup of ferrous iodide, 
and wine of iron may also be used with advantage when indicated in 
these little patients. 

In full doses, and especially in children, quinine sometimes acts as 
an antipruritic. For the same purpose calcium chloride in full doses 
answers well in some cases. Antimony in small doses as an alterative 
and nerve-tonic or in large doses to reduce vascular pressure is often 
of value. 

Beside those enumerated above may be named the following articles, 
which, after internal administration, have been reported as efficient in 
the hands of various authorities : calx sulphurata, viola tricolor, sodium 



^ss; 


15 




3j; 


4 




f'3ss; 


2 




"Uj; 




2 


fgvj; 


180 


M. 



ECZEMA. 337 

hyposulphite, ichthyol, chrysarobin, tar, carbolic acid, sulphur, pilo- 
carpine, and turpentine. 

Arsenic, which has been so largely employed by the general prac- 
titioner in eczema and in other disorders of the skin, is an uncertain 
remedy in all cutaneous diseases; it is equally uncertain in eczema, 
and has unquestionably aggravated as many cases as it has relieved. 
Its value in some chronic papular and squamous forms of the disease is 
undoubted, and in small doses as a nerve-tonic it is often of value, but 
it should never be given in acute cases or where there is any digestive 
disturbance. If arsenic, which certainly does possess an influence over 
the skin, has been demonstrated to have little or no value in the large 
proportion of all cases of eczema, what can be said for the host of other 
drugs, too commonly employed for a similar purpose, that are inferior 
to arsenic in their cutaneous effects? Sunlight, fresh air, suitable 
clothing, and due regime as to pleasure and business, must be, for 
many patients, controlled by the physician. These agencies do not cure 
eczema; but they do much to aid in its management; they may do 
more, if neglected, to furnish sources of its aggravation. Crocker 
advocates counter-irritation over the spine — over the nape of the neck 
for eczemas of the upper segment of the body ; over the dorso-lumbar 
vertebrae for the lower parts. Jackson has used the ice-bag with 
advantage in the same way. Counter-irritation of the corresponding 
part of the lateral half of the body for the relief of an eczematous patch 
of long standing limited strictly to the other side may also be employed 
in rare cases. 

(B) Local Treatment. — Local treatment is of value in all cases of 
eczema, is usually imperative, and often is the only treatment necessary. 
The remedies recommended for external application in the various 
forms and phases of eczema are so numerous and varied that barely to 
mention all would require many pages ; and not even the expert can 
be sufficiently familiar with them all to use each intelligently. A com- 
paratively small number of remedies skilfully handled will suffice in 
all but rare cases. It often happens that in a given type of the dis- 
ease a treatment which one physician uses with brilliant success fails 
utterly to serve a fellow-practitioner who is equally skilful, but who is 
less familiar with this particular method. One of the most common 
errors in the local treatment of eczema lies in the frequency with 
which, in a difficult case, a succession of new medicaments is tried 
instead of studying more carefully the details of application of familiar 
remedies. It must not be forgotten that each individual skin, like its 
possessor, has its idiosyncrasies. A remedy that in a given type of 
the disease will commonly give prompt relief, may in others prove of 
no benefit and even aggravate the condition. An idiosyncrasy may 
exist forbidding the use of particular drugs, such as carbolic acid, 
glycerin, resorcin, etc., or it may prevent the employment of certain 
classes of applications, as, for example, ointments, powders, lotions, 
etc. The choice of remedies must further be influenced in each case 
by a consideration of the type or phase, severity, and duration of the 
disease, of the region and extent of surface involved, of the age, occu- 
pation, and climatic and other surroundings of the patient. 



338 INFLAMMATIONS. 

The general objects and principles of treatment in eczema may con- 
veniently be grouped under the following heads : (1) exclusion of 
all sources of irritation to the skin ; (2) relief from pruritus, burning, 
and other morbid sensations ; (3) antiseptic dressing ; (4) reduction of 
local congestion in acute, and stimulation of circulation in chronic, 
cases ; (5) repair of the horny layer in acute, and destruction of the 
thickened and abnormally keratinized horny layer in chronic, forms of 
the disease. 

1. Exclusion of all Sources of Irritation. — This is the 
most important, the most varied, and often the most difficult and 
complex problem of all. Its full solution, however, will in the 
majority of cases fulfil all the other indications for treatment. Fre- 
quently a simple protective dressing is all that is required ; more com- 
monly the object is not so readily attained. The irritation of the skin 
due to its malnutrition or to conditions of ill health must be relieved 
in accordance with the principles of internal medicine, as has been 
indicated in discussing the internal treatment of eczema. 

The exclusion of all sources of irritation necessitates, secondly, the 
avoidance of all injurious external contacts. Only gross ignorance or 
carelessness will overlook the fact that the inflamed skin, like the in- 
flamed bone or the inflamed bladder, calls imperatively for rest. The 
prevalent idea, however, is that the patient with an inflamed joint 
retires to his couch or bed, while the patient with an eczema, if his dis- 
ease be not so formidable as to necessitate temporary withdrawal from 
the pursuits of business or of pleasure, belongs always to the peri- 
patetic class. He consults a physician, swallows some medicine, 
anoints his eczematous skin with a salve, and returns to the vocation 
in which his complaint was begotten. The baker goes to his baking ; 
the seamstress still pushes her needle through the dyed fabrics which 
first injured her hand ; the man with an eczema of the thigh walks the 
street with his trowser-leg rubbing the affected surface ; the nursing- 
mother with an eczema of the inframammary region still suffers the 
milk chemically altered in the heat of summer to flow over the tender 
surface of the breast, or in the case of her infant affected with eczema 
stuffs the folds of a coarse diaper half laundered or yet covered with 
the dejection from the bowels between its thighs and over the anal 
region. When a patient from necessity or from choice continues in 
the vocation or conditions which are largely or wholly responsible for 
the persistence of his malady he should distinctly understand that his 
recovery will be much slower and more uncertain than it would be 
with the rest and protection that every inflamed organ demands. 

Next is involved the exclusion of all topical irritants (in the hands 
of either physician or patient) designed to relieve the disorder, but 
having a precisely opposite effect. The number and variety of these 
medicaments are far from being commonly appreciated ; some are useful 
in advanced stages of the disorder, and harmful in its earlier periods. 
These articles, which are generally ordered by persons with a limited 
experience in diseases of the skin, represent a long list of stimulating 
and astringent ointments. Some are employed in sheer ignorance of 
their effects, as, for example, crude petroleum, strong acids and alka- 



ECZEMA. 339 

lies, silver nitrate, turpentine, and concentrated solutions of corrosive 
sublimate, intended to " burn out " the disease. 

Lastly, the exclusion of all sources of irritation necessitates protecting 
the involved surface from the excoriations and other traumatisms pro- 
duced by scratching, rubbing, and excessive washing of the eczematous 
skin, and from the irritation caused by exposure of the inflamed sur- 
face to the air. The various applications and protective dressings here 
serve their purpose, but in the case of adults some restraint to pre- 
vent rubbing and scratching is also needed ; in the case of infants this 
restraint may need to be enforced. Fixed dressings are often of great 
value in immobilizing a part, or in preventing friction, bruising, or 
other injury to the inflamed surface. A light elbow-splint to prevent 
flexion of the joint often is of service in keeping the fingers from the 
face. Most patients have to be repeatedly and forcibly impressed 
with the fact that a few minutes of scratching or rubbing, or one 
untimely washing of the inflamed surface, or its unnecessary expos- 
ure to the air may undo all that has been gained in several days of 
patient and successful treatment. This exclusion of all sources of 
irritation to the skin is essential to the proper treatment of every case 
of eczema. 

The great importance of rest and freedom from irritation of all sorts 
in eczema is well illustrated by the newborn infant, whose sensitive 
skin responds early to its first harsh acquaintance with the outer 
world by an explosion of eczema. It is a fact of importance that 
no child is born into the world eczematous. If the nervous system 
a^one were responsible for infantile eczema, such a result might occur, 
for that system is not only capable in intra-uterine life of producing 
club-foot and other deformities, but also of influencing skin-disorders. 
In the case of pigmentary moles visible at birth the lesions are often 
located along the distribution of one or more nerves. If the blood 
alone were responsible for eczema, the foetus surely might display its 
lesions, as it does those of syphilis. Animal poisons, as those of 
variola and scarlatina, do not spare the unborn child ; nor is it exempt 
from certain diseases of the integument that are generally regarded 
as due solely to tissue-changes, since newborn infants are occasionally 
seen affected with ichthyosis or sclerema neonatorum. 

Why is the tender skin of the foetus exempt from every form of 
eczema, and the tender skin of the infant accessible to each by such 
various approaches ? Will it be responded that the child has begun to 
respire and digest for itself; that it has become suddenly strumous, 
dartrous, rheumic, arthritic, gouty, or herpetic ; that its standard of 
health is impaired ; that it is suffering from assimilative, nutritive, or 
nervous debility, or from any one of the other numberless perturba- 
tions to which eczema may be a'scribed? AYhile nutritive and other 
constitutional changes undoubtedly have their influence, it would cer- 
tainly seem that the difference between the child unborn and the child 
born is, as regards eczema, a difference chiefly of skin-protection and 
skin-exposure. The former enjoys what White has aptly termed a 
"prolonged, placid, subaqueous life." Anointed with unguent and 
immersed in its water-bath of grateful temperature, its skin cannot be 



340 INFLAMMATIONS. 

fretted to produce an eczema. The child, abruptly and often rudely- 
brought into contact with the outer world, may speedily exhibit the 
most formidable symptoms of the disease. 

If any apology be needed for the space devoted to this part of an 
exceedingly interesting subject, it must be based upon the great fre- 
quency of the disease, the wide diffusion of erroneous doctrines re- 
specting its nature and the method of its management, and the mischief 
resulting from the too common aggravation of the malady in its earliest 
manifestations, due largely, on the part of both physicians and laymen, 
to a lack of appreciation of the fact that an inflamed skin needs rest 
and protection as much as does any other similarly affected organ of 
the body. 

2. Relief of Pruritus. — The itching, burning, and other sensa- 
tions which accompany eczema are usually largely or entirely allayed 
by the complete protection of the skin from irritation. Antipruritics 
are, however, frequently desirable and necessary. Among the best are 
carbolic acid, hydrocyanic acid, camphor, menthol, and salicylic acid, 
each in the strength of 0.5 to 2 per cent, (rarely stronger) in lotions, 
ointments, jellies, pastes, etc. Saturated solutions of boric acid, or the 
lead-and-opium wash, answer in many acute cases. If a remedy does 
not relieve the itching, it should be changed for one that will, unless 
the fault lies in the method of application. The most common error 
in the use of local remedies is found in the five- and ten-minute, or 
longer, intervals during which the skin is not protected, either as a 
matter of convenience or of appearance or as a result of carelessness 
in removing and reapplying the dressings. Exposure to the air for a 
few seconds only of an acutely inflamed surface may be sufficient to 
arouse a violent attack of itching or burning. The relief of pruritus 
by the use of drugs internally is considered under the head of internal 
medication. 

The necessity of relief is so imperious that at times the itching 
overshadows all other symptoms of the disease. He who has never 
studied the case of a man, a woman, or a child, possessed with a fuiious 
impulse to relieve an intense eczematous pruritus has not yet completed 
an education in medicine. This fury, for such it really is, has been 
likened to the sexual orgasm, with which it is undoubtedly allied, as 
the two are not rarely coincident when there is severe anal or genital 
itching. The features of the patient are drawn ; he is but half- 
conscious of his ejaculations and surroundings ; with his nails, or other 
object which he employs, he attacks the too vulnerable skin with an 
incalculable savagery. In these exaggerated paroxysms nothing but 
blood will suffice for his relief. Not until the torn and wounded sur- 
face oozes with red drops at every point does he emit the sigh which 
indicates that his desire is satisfied. • Men and women forcibly with- 
held from doing themselves this severe damage will at times exhibit 
the muscular spasm, facial expression, and movements of body scarcely 
distinguishable from the symptoms of petit mat in an epileptic seizure. 

3. Antiseptic Dressing. — It is not known to what extent eczema 
may be due to, or may be modified by, the various micro-organisms 
that come in contact with the skin, but severe cases are undoubtedly 



ECZEMA. 341 

complicated and prolonged by the action of such bacteria, and it is well 
in every case, when possible, to prevent their activity. Simple protec- 
tion does much to accomplish this end, while, fortunately, most of the 
remedies used as antipruritics are also more or less parasiticidal. In 
certain forms of the disease, such as seborrhoeal eczema, sulphur, resorcin, 
and other parasiticides are necessary. 

4. Belief of Local Congestion. — This is accomplished by posi- 
tion, compression, internal treatment, and largely by the removal of 
external irritation. Occasionally a direct astringent action may be 
obtained by the use of lead- water, lime-water, or by some of the rapidly 
drying jellies or glycerogelatin preparations. In chronic eczema pas- 
sive congestion is removed by means of stimulating washes, soaps, 
ointments, etc. 

5. Repair of the Epidermis. — If the preceding indications are 
fulfilled, repair takes place naturally. It may be aided and hastened 
somewhat in suitable cases by the use of very mildly stimulating 
remedies, such as weak preparations of sulphur, resorcin, ichthyol, 
thiol, tar, etc. In chronic cases with much thickening of the epidermis 
the abnormally and imperfectly keratinized horny layer must be de- 
stroyed and removed before the process of repair can begin. For this 
purpose salicylic acid in ointment is especially valuable. Other reme- 
dies used for the purpose are tar, sulphur, resorcin, chrysarobin, pyro- 
gallol, etc. 

Local Treatment of Different Types and Phases of Eczema. 1. Acute 
and Subacute Eczema. — In selecting remedies for use on the acutely 
inflamed integument it is always best to begin with one that is mild 
and soothing, and to make the application to a small surface only, until 
it can be determined that the preparation is going to operate favorably 
in the case at hand. So greatly do individuals differ in their response to 
a given remedy that it is often well to order an alternative treatment 
in case the first does not prove satisfactory. A remedy that induces 
comfort and brings relief to the patient will usually do good, while 
one that irritates will almost invariably do harm. One of the most 
important things to be remembered in the treatment of acute eczema is 
that the acutely inflamed skin does not tolerate pure water. The skin 
should be washed as little as possible, and this without soap and with 
soft water or with water that has been softened by the addition of 
borax, soda, bran, oatmeal, gelatin, or other demulcent, as outlined in 
the description of baths in the chapter on General Therapeutics. Hot 
water thus prepared and applied either as a lotion, a bath, a fomenta- 
tion, or by sponging (without rubbing), is frequently grateful and alle- 
viates the itching. If employed at all, its use should immediately be 
followed, as soon as the part is carefully dried, by the medicament 
selected for topical application, such as an oily or fatty substance, or a 
dusting-powder. ' In exceptional cases the continuous application of 
the cold pack may be of value, or, when it can be obtained, the con- 
tinuous immersion of the inflamed surface, which has been previously 
covered with an ointment, in water of a constant temperature. Dur- 
ing the acute stages cleansing of the skin can usually be accomplished 
best by the use of olive- or other oil. For the removal of crusts and 



342 INFLAMMATIONS. 

other accumulations a bland oil may be poured frequently over the 
surface with gentle inunction or be applied on lint or gauze. 

Even the oils, however, are at times sources of irritation. They 
are made more soothing if combined with an equal part of liquor 
calcis to form a liniment, as in Carron oil, constituted of equal parts 
of linseed-oil and lime-water. For the linseed-oil, which has a ten- 
dency to dry and form a dense coating on the surface, it is frequently 
better to substitute olive-oil, oil of sweet almonds, cod-liver oil, palm- 
oil, or lard-oil, flavored very slightly with bergamot or with lavender 
to correct the disagreeable odor. The addition of 1 per cent, of car- 
bolic acid makes the mixture antipruritic and mildly antiseptic. A 
thick emulsion may be formed by shaking together fresh lard and 
lime-water. In many cases the value of these dressings is greatly 
enhanced by surrounding the whole with oiled silk or other im- 
permeable tissue. Such dressing should not be applied continuously 
for many hours at a time for fear of macerating and weakening the 
skin. 

Poultices. — Flaxseed, linseed, starch, or other poultices may 
in exceptional cases be applied for a few hours at a time to soften 
crusts and other accumulations on the surface. They should not 
be retained long enough to produce congestion and maceration of the 
skin. 

Powders are useful in acute erythematous or papular eczema, in 
intertrigo, and occasionally in vesicular forms of the disease. Applied 
to a discharging surface, powders tend to form coherent crusts which 
retain secretions and are therefore irritating to the skin. In early 
stages when the discharge is slight, powders will sometimes succeed in 
wholly arresting the secretion. For this purpose they are of special 
value in mild forms of intertrigo. To prevent friction of underwear 
upon the skin the meshes may be filled with a fine powder. In eczema 
of the hands the gloves may be treated in the same way. For absorp- 
tive purposes magnesium carbonate is one of the most effective. For 
use on dry surfaces zinc stearate, plain or combined with boric acid, 
salicylic acid, thiol, acetanilid, etc., is very valuable on account of its 
lightness, and because it will adhere to any surface over which it is 
lightly rubbed with the hand. Among other excellent powders may 
be mentioned talcum, lycopodium, starch, rice-flour, " cimolite," bis- 
muth subnitrate, zinc oxide, and calamin. The following formulae are 
good: 



R Acid, boric, Z'\) ', 8 

Talc, 3^' J 24 

01. ros., q. s. q. s. 

R Acid, boric, £ij ; 8 

Zinc stearat., £»ij ; 8 

Talc, ^ss ; 16 

01. amygdal. amar., q. s. q. s. 



M. 



M. 



Anderson's powder and others containing camphor relieve pruritus 
better than the simpler powders, but are usually too stimulating and 
irritating for use in acute cases. In the preparation of dusting-powders 



ECZEMA. 343 

it is of the utmost importance that they be made impalpable by sifting 
them carefully through silk bolting-cloth, as they are sources of irrita- 
tion when they contain gritty particles. Only the best and finest 
grades of zinc oxide, talcum, calamin, and other powders should be 
employed, as many of the coarser grades found in the market cannot be 
rendered fine enough for use by any means at the command of the 
average chemist. 

Lotions are probably the most valuable preparations in acute and 
subacute eczema, and in some of the chronic forms of the disease. 
They are especially valuable in moist eczema, where it is necessary to 
protect the surface and relieve the itching, and at the same time to avoid 
the retention of secretions by the dressing. The chief drawback to the 
use of a lotion lies in the necessity of its frequent application to pre- 
vent drying. This objection may be removed partially by the addi- 
tion of 2 per cent, or more of glycerin or of tragacanth-mucilage. 
The effect of a lotion is further prolonged by the addition of some 
impalpable and inert or astringent powder, such as talcum, zinc oxide, 
bismuth subnitrate, or calamin. The powder, temporarily held in 
suspension by shaking the lotion immediately before each application, 
is thus left as a deposit upon the skin. A similar but less uniformly 
diffused effect is produced by the use of a dusting-powder immediately 
after the application of the lotion. In moist eczemas a better method 
is to keep the lotion constantly applied on gauze or other material in the 
form of wet dressings. Great care must be exercised in the removal 
of such dressings after they have become dry, for fear of wounding the 
skin. An effective method is to put a single layer next the surface, 
which is removed but once or twice in twenty-four hours or only when 
soiled or stiffened by excretions, while a number of outer and thicker 
layers may be changed frequently in order to keep the dressing wet. 

Lotions may be sedative, astringent, or stimulating. Many and 
varied formulae are recommended, but few only of the most useful and 
typical are given here, together with some suggestions as to their 
occasional modification. One of the most useful lotions, and one that 
is easily procured, is the following : 



B Acid, carbolic, 9ij ; 2 

Zinc. oxid. ? 5j ; 4 

Glycerin., £ij ,* 8 

Aq. calcis, q. s. ad o vn J > <!• s - a d 240 



66 
M. 



The quantity of any one or all of the first three ingredients may be 
increased or diminished as desired. Where carbolic acid does not act 
favorably dilute hydrocyanic acid may be substituted. The zinc may 
be replaced partially or wholly by one of the other powders mentioned 
above. Tragacanth-mucilage may be used instead of glycerin, or both 
may be omitted and half of the lime-water be replaced by an equal 
quantity of elder-flower water. By the use of one or more of these 
suggested changes may be formed the well-known Starting lotion and 
its modifications, and the several compound zinc-oxide lotions ; among 
the most desirable are : 



344 INFLAMMATIONS. 

B 



Acid, hydrocyan. dil., 


3ss-5ij ; 


2-8 




Zinc, oxid., | 
Calamin., J 








aa 3j ; 


4 




Aq. calcis, j 
Aq. sambuci, j 


aa 5iv; 


120 


M 


Acid, carbolic, 


5ss-5ij ; 


2-8 




Bismuth, subnit., 


35; 


4 




Tragacanth., 


gr. xl ; 


2 


6Q 


Aq. calcis, 


^viij ; 


240 


M 



B 



Occasionally neither carbolic acid nor hydrocyanic acid has the 
desired antipruritic effect, even when increased in strength to 5 per 
cent., or both may be contraindicated for some reason. In such cases 
from 1 to 3 per cent, of menthol, camphor, or chloral may be added, 
with sufficient alcohol to hold them in solution. With these additions 
the lotion becomes more or less stimulating and must be used in acute 
cases with great caution. 

The following lead-and-opium wash is as useful as the various zinc 
oxide lotions, and in weeping cases with burning or hyperesthesia is 
usually more acceptable. 



B Tinctur. opii, ^ss; 15 

Liquor, plumbi subacetat. 
dilut., q. s. ad ^viij ; q. s. ad 240 



M. 



To this may be added, as in the case of the zinc oxide lotion, gly- 
cerin, boric acid to saturation, zinc oxide, or other powder to be left on 
the skin as a deposit, or from ^ to 1 ounce (15. to 30.) of tincture 
of camphor if this is well tolerated and a more decided antipruritic 
eifect is desired. 

A saturated solution of boric acid to which has been added 2 per 
cent, or more of glycerin or tragacanth-mucilage is an excellent appli- 
cation in moist eczema, and especially in suppurating forms. A weak 
solution of potassium permanganate is both antiseptic and antipruritic. 
Black wash pure or diluted is effectual in many moist forms of eczema, 
as are 1 to 10 per cent, solutions of ichthyol and thiol. Excellent 
lotions for soothing effect are made by adding 1 to 2 drachms (4.-8.) 
of sodium bicarbonate or biborate to a quart (1000.) of thin oatmeal- 
gruel or of marshmallow-decoction. For a dry, irritable, and itching 
ezcema, Boeck recommends the following : 



B 



Talc, \ 
Amyli, J 


aa |ij ; 


60 


Glycerin., 


3yj; 


24 


Liq. plumb, subacet. dil., 


<fiv; 


120 



M. 



This is to be diluted with 2 parts of water, and applied with cotton or 
a brush. This lotion is decidedly cooling, but is not indicated in moist 
eczema. 

The COMBINED USE OF LOTIONS AND OINTMENTS will often give 

good results. The black wash as recommended by Duhring, White, 
and others is often effective in acute vesicular eczema. The part is 



ECZEMA. 345 

bathed for fifteen or twenty minutes two or three times a day with 
the wash, the sediment allowed to remain on the skin, and the whole 
covered with a piece of gauze or soft cloth on which has been spread a 
thick layer of zinc oxide or other simple ointment. The lead-water 
or the zinc oxide lotions may be used in the same way with simple 
ointments or pastes. 

Any one of the zinc oxide lotions described above may be combined 
with an equal quantity of almond-, olive-, or other oil to form a Lini- 
ment. These combinations are especially good in acutely inflamed 
surfaces of considerable extent. As has been stated, they are also 
useful for cleansing the surface of crusts and other accumulations. To 
this end their action can be hastened and made more effective if an 
impermeable dressing be superimposed. For therapeutic purposes, 
however, the rubber and other impermeable dressings are rarely called 
for in acute eczema. 

For subacute and indolent stages of eczema and for some acute cases 
mildly stimulating and stronger antipruritic lotions containing tar, car- 
bolic acid, menthol, camphor, chloral, and alcohol may be used. They 
should be tried cautiously and diluted at first. As a rule, they give 
best results when applied for a few moments several times a day, the 
part being kept covered in the interval with an ointment or other pro- 
tective dressing. The following formulae, which may be modified to 
suit individual cases, are to be recommended : 

R Acid, carbolic, 3iss-^ss; 6-15 

Glycerin., 5ij ; 8 

Menthol., Sj-^ss ; 4-15 

Spirit, vin. rect., q. s. ; M. 

Aq. destill., q. s. ad ^viij ; q. s. ad 240 



R Liq. picis alkalinus, 3ss-3ij ; 2-8 

Glycerin., £ij ; 8 

Aq. destill., q. s. ad ^viij ; q. s. ad 240 



M. 



Liquor carbonis detergens or Duhring's compound tincture of coal- 
tar (these preparations are described under Chronic Eczema) may be 
substituted for the liquor picis alkalinus. The fluid extract of grin- 
delia robusta in the strength of from 1 to 2 per cent, in water is 
recommended by Duhring for some forms of subacute papular eczema. 
It should be used with caution, as it frequently irritates the skin. 
Hutchinson recommends the following in dry, subacute eczema : 



R Liq. plumb, subacet., £ss ; 2 

Liq. carb. detergentis, £ss ; 2 

Aq. destill., q. s. ad 3viij ; q. s. ad 240 



M. 



Ointments are not, as a rule, well tolerated by an acutely inflamed 
skin, and are commonly more useful in subacute and chronic eczema, 
but there are many exceptions to the rule, and occasionally even an 
acute vesicular eczema is best relieved bv use of an ointment. In the 



346 INFLAMMATIONS. 

application of ointments care should be taken that they are properly 
and freshly prepared, and that the debris of one dressing is carefully 
removed before another application is made. Strata of any ointment, 
the older next the skin possibly rancid and having imprisoned beneath 
them pus or other products of disease are a source of positive harm. 
In acute, and especially in weeping, eczemas an ointment is best applied 
by spreading it evenly on gauze, lint, or other soft material, which can 
then be laid upon the part. The salve-muslins devised by Unna 
furnish an excellent substitute for ointments; they are clean and effec- 
tive, and in every way admirable if they can be procured fresh. They 
are, in this country, expensive, and as they deteriorate rapidly it is 
often difficult to obtain them in proper condition for use. 

Among the best ointments for use on the acutely inflamed skin is 
the well-known diachylon ointment of Hebra. It is prepared as 
follows : to 14 ounces of the best olive-oil are added 1 pound of water, 
and the whole heated to boiling on a water-bath ; 3 ounces and 6 drachms 
of finely powdered litharge are sifted slowly into the liquid, which is 
then boiled and stirred constantly until all particles of litharge have 
disappeared and there is formed a perfectly homogeneous mass. During 
the cooking water is occasionally added as required, and the whole 
evaporated to the desired consistence. The stirring is to be continued 
until the ointment is cold. While the mass is cooling 1 drop of oil of 
roses or of oil of lavender is added to each 2 ounces of ointment. 
When properly prepared the Hebra ointment is perfectly homogeneous, 
is of a light-yellowish color, and is of the consistency of butter. It is 
technically known as the " Unguentum diachyli albi " of Hebra. The 
simple ointment often becomes rancid in two or three weeks, but it may 
be preserved for months by the addition of 0.5 per cent, of carbolic acid 
or formalin. 

Duhring has modified this ointment as follows : 1 part of pure dry 
lead oxide is rubbed down with 1 part of water, and well mixed with 8 
parts of the best olive-oil. The mixture is stirred for about two hours 
over a water-bath near the boiling-point, and is then cooled with 
constant stirring until the proper consistence is obtained. The oint- 
ment has been modified by Piffard, and after him by Kaposi, in com- 
bining equal parts of lead-plaster and vaselin. It may be imitated 
fairly well by melting together 3 or 4 parts of olive-oil and 4 of 
diachylon plaster, and stirring until cool. 

The Hebra ointment, though useful often in full strength and even 
to the exclusion of other pomades, may often be combined with others 
with manifest advantage. Thus, 1 or 2 drachms (4.-8.) of it may be 
added to the ounce (30.) of lard, cold-cream salve, or cerate, with or 
without the addition of another drachm or two (4.-8.) of zinc oxide 
ointment. 

The officinal zinc oxide ointment is an acceptable preparation in 
many acute cases ; equal parts of this and the Hebra ointment make 
an excellent combination. Any one of these ointments may be reduced 
with from one to three times its volume of lanolin, vaselin, or cold- 
cream salve. The following formula gives an excellent soothing and 
protective ointment : 



ECZEMA. 347 

R Bismuth, oxid., 3j ; 4 

St: } aa ^ 30 

Cerse alb., 3iij ; 12 

01. ros., q. s. q. s. M. 

Other bland and soothing ointments may be made by combining in 
various proportions cold-cream salve, lanolin, vaselin, lard, and simple 
cerate. The cerates are made sufficiently soft for gentle manipulation 
by adding 1 or 2 drachms (4.-8. to 30.) of glycerin or oil to each 
ounce of ointment, and they may be flavored with lavender, rosemary, 
or bergamont, as preferred. These simple bases may be stiffened and 
rendered somewhat astringent by the addition of from 10 grains to a 
drachm (0.60 to 4.) or more of bismuth subnitrate or subcarbonate, zinc 
oxide, or calamin to the ounce (30.). A very thin base may be prepared 
by mixing equal parts of lanolin, olive-oil, and glycerin. This is espe- 
cially valuable for use on hairy surfaces. A creamy and cooling base 
is Unna's "refrigerant ointment," which contains lanolin, 10; lard, 20, 
and rose-water, from 30 to 60 parts. Any of the above bases may be 
medicated as desired ; the most frequent addition being from 5 to 10 
grains (0.30-0.60) of carbolic, boric, or salicylic acid, or a similar quan- 
tity of calomel or white precipitate to the ounce (30.) of salve. With 
these unguents may be named glycerole of starch, cucumber ointment, 
emulsion of sweet almonds, decoction of Irish moss, and Hardy's 
formula — 2 parts of zinc oxide, 8 of glycerin, 30 of cold-cream salve, 
and 15 drops of tincture of benzoin. 

The oleate of bismuth or of zinc is prepared by rubbing up 1 drachm 
(4.) of the oxide of either metal with 8 (30.) drachms of oleic acid, and 
allowing the mixture to stand for two hours. It is afterward heated 
on a water-bath, where 10 drachms (40.) of vaselin and 3 (12.) of wax 
are dissolved in it, and the whole stirred until cold. This ointment 
is especially useful when employed in papular forms of eczema. In 
pustular eczema ointments containing iodoform, boric acid, iodol, aris- 
tol, or europhen are indicated. 

Pastes are especially valuable in subacute eczema, and are often 
tolerated in acute forms of the trouble better than an ointment. A 
thick paste is rarely indicated in moist eczema, as it prevents escape 
of the discharge from the surface. Pastes are more cleanly and 
adhesive, furnish better protection, are more drying, and require less 
frequent applications than ointments. They are formed by combining 
a simple powder with an ointment-base, and may be medicated by the 
addition of various remedies. The following paste recommended by 
Lassar may be taken as a type : 



R Amyl., 

Zinc, oxid., 
Vaselin., 



3y; 


8 


3ij; 


8 


^ss; 


15 



M. 



The substitution of talc for the starch in the above gives a paste 
with less tendency to concrete in lumps on the skin. Duhring uses 
boric acid in place of the starch, and thus produces a stiff and adherent 
paste. A very smooth and pleasant combination, and one that is also 



Sij; 


60 
30 


3j; 
ly, 


4 
30 



348 INFLAMMATIONS. 

fairly stiff and adherent, is made of equal parts of talc, zinc oxide, 
vaselin, and lanolin. These pastes serve as bases to which various 
medicaments may be added. Those most commonly used in acute and 
subacute eczema contain boric, salicylic, and carbolic acids, in the 
strength of from 1 to 5 per cent. ; calomel, white precipitate, ichthyol, 
and thiol in similar proportions. Other remedies may be employed 
according to the indications. As an adherent and drying paste Duhr- 
ing recommends : 

1& Lanolin., 
Paraffin., 
Cerae alb., 
Aq. destill., ^j ; 30 M. 

The lanolin, paraffin, and wax are thoroughly mixed before the water 
is added. A good drying and soothing paste, recommended by Morris, 
is made of equal parts of almond- or olive-oil, lime-water, and zinc 
oxide. Unna recommends a paste prepared by mixing 1 ounce of 
zinc oxide with 2 ounces (30.-60.) each of glycerin and mucilage. 
To either of these pastes may be added 1 per cent, of carbolic or 
salicylic acid. Other good bases are found in Elliot's bassorin-paste, 
or Unna's gelanthum, both of which are described in the chapter on 
General Therapeutics. 

The Glycogelatins render excellent service in all dry forms of 
eczema, in which simply protection is required. Certain remedies may 
also be incorporated, such as 1 or 2 per cent, of ichthyol or thiol. A 
convenient formula is the following : 

R Gelatin, alb., \ aa ^j; 30 

Zinc, oxid., 



Or 



Glycerin., ^jss ; 45 

Aq. destill., Jiij ; 90 

B Gelatin, alb., 3ijss ; 10 

Zinc, oxid., 3v; 20 

Glycerin., ^j ; 30 

Aq. destill., 3x; 40 



M. 



M. 



The ingredients are mixed on a hot water-bath and when cool may 
be cut in pieces of convenient size for use. Before application a 
sufficient quantity is placed on a hot water-bath, or in a dish placed in 
a receptacle containing hot water, and applied with a brush. It dries 
somewhat slowly and it is well after two or three minutes to pat the 
surface with cotton or to cover it completely with gauze. By increas- 
ing the quantity of glycerin a softer and more slowly drying prepara- 
tion is formed. By lessening the quantity of glycerin and increasing 
that of the zinc oxide or gelatin a firmer and more rapidly drying 
product is obtained. Though these glycogelatins serve their best 
purpose in the dry forms of the disease, there are few forms of 
eczema in which they may not at times be used with benefit. In sub- 
acute and indolent types Pick's gelatin sublimate is useful. This is 
prepared by mixing 30 grammes of gelatin with sufficient water to 



ECZEMA. 349 

liquefy it on a water-bath, and evaporating to 75 grammes ; 25 grammes 
of glycerin and 5 centigrammes of corrosive sublimate are then added. 
The product must be melted before applying. 

In acute erythematous eczema Pick's Tragacanth Varnish (" lini- 
mentum exsiccans") is a very acceptable remedy in that it is easily 
applied without heating, dries quickly, is clean, and distinctly cooling. 
It is composed of tragacanth, 5 ; glycerin, 2 ; and boiling water, 93 
parts. To this may be added 1 or 2 per cent, of boric or carbolic acid, 
or from 2 to 5 per cent, of some simple powder, such as zinc oxide. 
The tragacanth must be soaked for several hours in a part of the water 
and thoroughly triturated before the other ingredients are added. 

2. Subacute Eczema. — Attention has already been called to the fact 
that no sharp line can be drawn between acute, subacute, and chronic 
eczema, the degree of inflammation in any given case varying from 
time to time. Most acute cases, however, are followed by a longer or 
shorter period of subacute or chronic inflammation. In proportion as 
the disease progresses to the subacute or chronic stage the various 
topical medicaments employed may be changed in character so as to 
produce an astringent or stimulating effect upon the part. The utmost 
skill and prudence, however, are needed at this juncture, and changes 
should be made cautiously, for it is at this time that the disorder is 
readily awakened to renewed activity, a turn of affairs which is espe- 
cially annoying to the patient, and particularly so to the practitioner 
if there be a suspicion (truth to tell, often too well founded) that the 
aggravation has been due to the treatment. 

Again, many cases of eczema are subacute and indolent from the 
beginning, yet are liable at any time to present acute manifestations ; 
consequently in beginning the treatment of an apparently subacute case 
it is well to use mild measures first, gradually changing to those stronger 
and more stimulating. 

The treatment of subacute eczema varies from that of the acute type 
chiefly in demanding more stimulating remedies and those having a 
greater antipruritic effect. For this purpose many of the substances 
already recommended for acute eczema may be employed, but in in- 
creased strength. In this phase of the disorder pastes are especially 
valuable, as are also the glycogelatins, though occasionally lotions and 
powders produce the best results. On the other hand, cases occur in 
which ointments make the best applications. When milder measures 
will not succeed in a given case the stronger remedies recommended for 
chronic eczema should be employed. 

3. Chronic Eczema. — The general principles of local treatment of 
chronic eczema are those of the acute form of the disease except that 
stronger and more stimulating remedies are used. It must be remem- 
bered that many chronic eczemas are subject to acute exacerbations, 
when milder and soothing treatment must be adopted for a time. 
Moreover, chronic eczema appears in such varied phases in different 
individuals, and in the same individual in successive attacks, that it is 
impossible to select certain formulae and declare that these will be of 
benefit in a given type of the disease. It fs only by a careful observa- 
tion of the general principles and objects of the treatment of eczema, 



350 INFLAMMATIONS. 

discussed in the preceding pages, that the varied conditions can be 
successfully treated. 

Cleansing of the skin should be accomplished according to 
directions already given, by means of oils or liniments, though in 
chronic eczema more vigorous measures can frequently be employed, 
including the occasional use of soap and water, some densely infiltrated 
patches tolerating and even being benefited by a daily washing. For 
this purpose a good toilet-soap, or, when the skin will permit, tincture 
of green soap may be used. The Sarg glycerin soap is an admira- 
ble substitute for these articles when the skin is tender and where an 
elegant toilet-preparation can be ordered. The crusts and scales once 
removed, subsequent topical applications can be made as required in 
each case. 

Powders are useful in chronic as in acute eczema for mechanical 
protection, to prevent friction between apposed skin-surfaces or be- 
tween the skin and clothing. They are often of value when dusted and 
patted over a paste, thus making a thicker and more cleanly dressing, 
and one less likely than a paste to be rubbed off. The Anderson and 
other antipruritic powders are frequently serviceable for application 
during the day, when other dressings cannot well be employed on 
account of the patient's occupation. 

Lotions' are of less value than in acute eczema, but are often use- 
ful for temporary purposes after the skin has been unduly irritated 
by other dressings. Stimulating lotions or solutions are sometimes 
painted on the skin and allowed to dry, or are used for a few minutes 
each day, the surface in the intervals being covered with an ointment. 

Ointments are the preparations most used, especially in the dry, 
scaly forms of the disease, in which penetration of the remedy is 
desired. To serve this end, they should be gently rubbed into the sur- 
face, which is later covered with more of the same ointment spread on 
gauze or a soft cloth. 

Pastes often answer better than ointments, especially when protec- 
tion and drying of the surface are the chief objects of treatment. In 
combination with powders as described above, they furnish convenient 
and effectual applications in most cases of chronic eczema. In many 
dry forms of the disease either plain or medicated Glycogelatins 
form the best application. They are of special value in dispensary 
and other cases in which the physician does not wish to entrust the 
dressing to the patient, as a gelatin-dressing may often be left in place 
for several days or a week. For the application of tar, chrysarobin, 
salicylic acid, and a few other remedies to small areas, Collodion and 
Fluid Gutta-percha (Traumaticin) form convenient and cleanly 
vehicles. 

Applications in chronic eczema, as a rule, should be more antipru- 
ritic and more stimulating than in acute and subacute phases of the dis- 
ease. The remedies recommended above may be used in increased 
strength. This is especially true of the drugs classed as antipruritics, 
such as carbolic acid, creosote, camphor, menthol, and chloral. 

One of the most useful remedies in chronic eczema is, Salicylic 
Acid, It is antipruritic and is very effective in destroying thickened 



ECZEMA. 



351 



areas of dry horny epidermis. It may be incorporated in the strength 
of from 2 to 10 or even 20 per cent., in most of the ointments, pastes, 
and plasters recommended in the preceding pages. In the glycogela- 
tins more than 2 or 3 per cent, cannot be used without the addi- 
tion of a fat, preferably 5 per cent, of fresh lard. For small areas of 
infiltration with marked thickening of the horny layer salicylic acid is 
best used with Duhring's modifications of Pick's "salicylated soap 
plaster." The acid has a tendency to soften the plaster if employed in 
strength above 5 per cent. Duhring's formulae are as follows : 



R Emplast. saponis (U. S. P.) 






liquefact., 


3"j; 


90 


Olei olivae opt., 


fffj; 


10 


Acid, salicylici, 


5ss; 


2 


For a 5 per cent, plaster : 






R Emplast. saponis (U. S. P.), 


5J > 


30 


Olei olivae, 


TT^ xxiv ; 


1 


Acid, salicylici, 


gr. xxiv; 


1 


For a 10 per cent, plaster : 






R Emplast. saponis (U. S. P.) 






liquefact., 


&; 


30 


Acid, salicylici, 


gr. xlvnj ; 


3 


For a 20 per cent, plaster : 






R Emplast. plumbi (U. S. P.), 


5j; 


30 


Cerse flavae, 


gr. xlvnj ; 


3 


Acid, salicylici, 


gr. cv ; 


7 



M. 



60 

60 M. 



20 M. 



20 



M. 



Plasters made according to the above formulae are adhesive, and are 
firm enough to be moulded and kept in rolls. For large surfaces they 
should be warmed before applying, to make them spread easily. Pesorcin 
and other remedies may be substituted for salicylic acid, but resorcin 
has a tendency to stiffen the plaster and requires the addition of oil. 
Unna's salicylated gutta-percha plaster-mulls make elegant substitutes 
for the above, but they are expensive and not always obtainable in this 
country. They, moreover, deteriorate rapidly, and if not fresh are not 
serviceable. 

Tar. — This is one of the most valuable remedies, when tolerated by 
the skin, for the treatment of chronic eczema. The preparations most 
commonly employed are pix liquida (pine-tar), oleum rusci (oil of white 
birch), oleum cadinum (oil of cade), and terebinthina Canadensis (bal- 
sam of fir). Oil of cade, as found in most of the shops, is inferior to 
oleum rusci. The tars are best applied in the form of ointments, but 
are occasionally painted over the affected surface in a liquid state with 
a camel's-hair brush. From \ to 2 drachms (2.-8.) of tar, in com- 
bination with a suitable quantity of potassium subcarbonate, are suffi- 
cient to add to 1 ounce (32.) of ointment, the proportions suggested 
being varied to suit the requirements of each case, 



352 INFLAMMATIONS. 

In beginning the use of tar with any individual, weak preparations 
should first be employed, and the strength be gradually increased until 
tolerance of the skin is determined, as an acute dermatitis not infre- 
quently follows the application of stronger preparations. A convenient 
method is to order one jar of a fairly strong tar ointment, and another 
of the zinc oxide, the Hebra, or other simple salve. Before the first 
application the patient takes a sufficient quantity of the simple oint- 
ment in the palm of one hand and mixes with it a very small propor- 
tion of the tarry preparation. If no irritation follows this application, 
the amount of tar can be gradually increased with each dressing until 
enough is used to relieve the itching and to cause the disappearance 
of the infiltrated area, after which a simple paste or powder may be 
employed until the skin has regained its normal strength and resist- 
ance. If the application at any time causes an acute dermatitis, sim- 
pler remedies for a time must be substituted. To accomplish the best 
results, tar ointments should be well rubbed into the skin or liquid 
preparations painted on. Sometimes it is well to permit the application 
to accumulate until thrown off by exfoliation ; but more commonly, 
and especially if there be signs of irritation, it is better to cleanse the 
skin with oil or with soap and water, according to indications, before 
each application. 

The following formulae are illustrations of the manner of compound- 
ing the various preparations of tar : 



R 01. rusci (vel cadini), 3ss-3iij ; 2-12 

Potass, subcarbonat., Bj - 3ss ; 1.33-2 

Unguent, aq. ros., §j ; 30 

Ft. ungt. 



M. 



For the potassic subcarbonate ^ to 1 drachm (2.-4.) of zinc oxide 
may be substituted, or from 2 to 4 grains (0.133-0.266) of red mercuric 
oxide, or yet -^ scruple (0.66) of mild chloride. The vehicle, also, 
of such ointments may be vaselin, lanolin, simple cerate, or ^ ounce 
(16.) of either in combination with an equal quantity of diachylon 
ointment. 

Of fluid preparations may be mentioned alcoholic solutions of tar, 
J ounce (10.) of the latter to the pint (500.) of alcohol ; and in cases 
in which the detersive action of soap is also needed sapo viridis may 
be added as follows : 



R 



Picis liquidae, 


f 3j-3ij ; 


30-60 


Sapon. virid., 


f Sjss-Snj ; 


45-90 


Glycerin., 


f&; 


30 


Spt. vin. rectif., 


f 3vnj ; 


240 


01. rosmarin., 


f 3ss; 


2 



M. 



Sig. To be rubbed gently into the skin with a flannel rag. 



Bulkley devised an alkaline solution of tar and caustic potassa, 
which is especially serviceable, as it is miscible with water in all 
proportions, and which is constituted as follows : 



ECZEMA. 353 

R Picis liquidse, f ^ij ; 60 

Potassse causticae, ^j ; 30 

Aq. destillat., §v; 150 M. 

Dissolve the potash in the water, and add slowly to the tar in a mortar 
with friction. 

Sig. " Liquor picis alkalinus." To be used diluted as a lotion. 

Of this solution 1 drachm (4.) or more may be added to a pint 
(500.) of water. As an ointment, the same quantity of the solution 
may be added to the ounce (30.) of cold-cream salve, lanolin, or 
vaselin. It should be remembered, however, that the caustic alkali 
renders this preparation exceedingly irritating to a sensitive skin, and 
it should be employed with caution upon any untested surface. 

An excellent fluid preparation is Duhring's " compound tincture of 
coal-tar," prepared according to the following formula : " Coal-tar 
(1 part) should be digested with tincture of quillaja (6 parts), with 
frequent agitation for not less than eight days, preferably for a longer 
period, and finally filtered. The resultant product is a brown-black 
tincture which, upon the addition of water, forms a cleanly yellowish 
emulsion, the color and certain other characters varying with the 
variety of coal-tar used. The strength of the tincture of quillaja 
should be 1 to 4 with 95 per cent, alcohol." Five to fifteen minims 
to the ounce of water is the strength recommended for use. 

The formula recommended by Spender, and described in the chap- 
ter on General Therapeutics, is a useful means of testing the efficacy 
of tar upon an eczematous surface. Olive-oil or cod-liver oil may be 
combined with equal parts of one of the tarry preparations and rubbed 
into the eczematous skin. When fluid or semifluid compounds of tar 
are needed upon the scalp 1 drachm (4.) of the article selected may be 
rubbed up with an equal quantity of glycerin and added to 6 ounces 
of cologne- water (180.). Creolin is very similar in its action to tar 
and is miscible with water. 

Hebra disclaimed any special value for sulphur in eczemas uncom- 
plicated by the acarus scabiei, but in Wilkinson's and other ointments 
it serves a good purpose. The following formula supplies an ointment 
rather less severe that has practical efficacy in chronic eczema : 



B 


Picis liquid, (vel. ol. 

Adipis, 

Ol. olivae, 


rusci), 




Jiv; 

Jj; 

gss; 




120 
30 
15 


Misce et adde : 














Terebinth. Canadens. 


'.} 




^r • 








Sulphur, flor., 


aa 


oJ > 


aa 6kj 


Sig 


To be applied three 


times d 


aily 


with 


a soft brush. 





M. 



To this formula may be added green soap if a stronger effect is 
desired. 

Ointments and pastes containing 10 to 30 grains (0.60-2.) of sulphur, 
and 7 to 15 grains (0.33 to 1.) of salicylic acid in similar proportions 
often give good results in circumscribed, infiltrated patches of eczema 
which show tendencies to occasional moisture and crusting. Oint- 
ments containing from 1 to 4 per cent, of sulphur favor keratoplasia. 

23 



354 INFLAMMATIONS. 

Ichthyol and thiol, in ointments of the strength of 10 per cent, and 
less, or in aqueous lotions containing from 5 to 50 per cent, of the 
drug, are useful in localized patches of the disease, especially of the 
papular and scaling varieties. Ammonium sulpho-ichthyol is prefer- 
able to the natrium compound. Its influence upon the skin seems to 
resemble both that of the tars and of chrysarobin. Unna's varnish 
containing ichthyol is convenient, as it dries rapidly and is easily 
removed by washing. It is prepared as follows : 40 parts of starch are 
mixed with 100 parts of water, to which are added 40 parts of ichthyol ; 
after thorough trituration there are added 1J parts of a concentrated 
solution of albumin which should be prepared at a temperature low 
enough to prevent coagulation. 

Other remedies which may be added to ointments, pastes, or plasters 
in strength varying from 1 to 10 per cent, for the treatment of chronic 
eczema are resorcin, chrysarobin, pyrogallol, calomel, and white precipi- 
tate. Occasionally systemic intoxication has followed the use of these 
remedies over large surfaces, and they are best adapted to employment 
on small areas. The three first named stain the skin and clothing. 
Other preparations of mercury may be employed with advantage in 
some cases. The use of resorcin in seborrheal eczema is considered 
with that subject. 

An effective method of treating circumscribed thickened patches of 
eczema is the following : a piece of green soap as large as a walnut is 
spread upon a flannel rag, and rubbed into the eczematous part for 
several minutes, pressing firmly the while, and from time to time 
dipping it into water in order to produce lather. The duration and 
firmness of the rubbing depend chiefly upon the amount of infil- 
tration present, but to some extent upon the general condition of the 
skin. The production of an acute dermatitis by too severe treatment 
should be avoided. Following the soap-rubbing the part is washed 
free from suds with water, carefully dried, and the oil or ointment 
selected for topical use immediately applied on strips of muslin, which 
are neatly bandaged to the part. Hebra ? s diachylon ointment is one 
of the best for this purpose. The soap must be rubbed in at least 
twice every day, so long as any excoriated points appear after its appli- 
cation. Soap rubbed into the healthy skin will not be followed by 
such effects, the part feeling clean, smooth, and comfortable after it 
has been washed. The contrast this offers to the eczematous part is 
very striking, the latter presenting numerous intensely red, raw, and 
moist spots. The appearance of these red, shining, moist points after 
the first inunction suggests to the inexperienced eye that the malady 
has been aggravated ; but they become fewer in number after each 
application, and finally disappear, the eczematous surface being then no 
more affected by the soft soap than is the surrounding healthy skin. 

Many circumscribed patches of chronic eczema are greatly benefited 
by daily painting with a saturated solution of pyoktanin-blue. It is 
unproductive of pain in the majority of cases in which it is employed, 
and, as it forms a thin scale over the surface to which it is applied, prob- 
ably serves a good purpose for the time being by the exclusion of air. 
It acts also as a parasiticide. When the effect is markedly beneficial 



ECZEMA. 355 

it leaves little to be desired in the way of local treatment. The chief 
objection to its employment lies in the staining it produces not only of 
the skin, but also of all articles brought into contact with it. 

Another valuable agent in the local treatment of these varieties of 
eczema is formalin, a solution representing 40 per cent, of formaldehyd. 
It is rarely tolerated by the skin in a strength greater than from 1 to 2 
per cent. 

Among the more severe measures occasionally employed for small 
patches of eczema which resist milder treatment may be named can- 
tharides employed as a blister, silver nitrate in crayon or in solution, 
from 3 to 60 grains to the ounce (0.20-4. to 30.), and iodine in combi- 
nation with carbolic acid. The following formula should furnish a 
clear vinous-red fluid, which may be applied pure or in dilution : 

R 



Sig. 



Iodin. tinct., 3ss ; 


2 


Acid, carbolic, (cryst.), 3j ; 


4 


Alcohol^ } ™ 3i J ; 


aa 8 


Aq. destillat., ad f^j; 


ad 30 


Iodized solution of carbolic acid. 





M. 



In cases in which there is considerable pruritus, especially in obsti- 
nate patches of papular eczema, the iodized phenol of Bellamy may be 
substituted for the above. The formula is : 

B S3l;} "*•• "M 

Combine with gentle heat and add an equal part of glycerin. 
Sig. Iodized phenol ; to be applied twice daily with a glass rod. 

Prognosis. — Eczema is an entirely curable disease, but uncertainty 
attends its prognosis as regards the duration of an attack and the prob- 
ability of the recurrence of a relapse. With respect to the questions 
most frequently asked, those relating to contagion, heredity, and 
persistent lesion-relics, a favorable response can be made ; but the 
fact remains that some forms of the disease are insignificant, some 
persistent, and some particularly liable to relapse from very slight 
provocation. Only after careful weighing of all the conditions exhibited 
by the skin and by the other organs can a reasonable probability as to 
the future of the disease be estimated. Eczema is a disease exceedingly 
common, and one subject to aggravation by causes well-nigh innumera- 
ble. Were the physician always in position absolutely to insure his 
patient a proper mode of living, and the exclusion of all sources of 
irritation to the skin, the prognosis would be much more satisfactory. 
In hospital-patients, over whom such control is more perfectly attained, 
the results of treatment may be predicted with some confidence. 

In general, it may be said that acute eczema is more readily relieved 
by proper treatment than are the chronic forms of the disease ; that 
eczema with a discoverable cause is more manageable than one the 
etiology of which is obscure ; that eczema of the very young and of 
the very old is at times particularly rebellious ; that the non-discharging 
phases of the disease are rather more persistent than those accompanied 



356 INFLAMMATIONS. 

by secretion ; that eczema lingering at the mucous outlets of the body 
(auditory canal, nostrils, mouth, nipple, anus, vagina) is more obstinate 
than when it affects the skin of other parts (shoulder, neck, lumbar 
region) ; that eczema with constant aggravation or complications (fissure 
of skin of hand, varicose veins of leg, apparatus for anchylosis) is 
more stubborn in proportion as these complications or aggravations 
cannot, from the circumstances of each case, be set aside ; and, finally, 
that an eczema which has long existed, or has repeatedly recurred, as, 
for example, with every season of extremely cold or hot weather, is, 
after relief, very liable to return. Eczema seborrhceicum (dermatitis 
seborrheica) affords brilliant results in all well-managed cases. The 
parasitic eczemas are also particularly amenable to treatment. 

Topical and Special Varieties of Eczema. 

Eczema of Children. — Inflammation of the skin in infants and 
young children is usually acute in type, owing to the delicate struct- 
ure of the skin and to the tendency in childhood to acute rather than 
subacute and chronic pathological changes in the various organs of the 
body; consequently the eczema of infants is commonly vesicular, 
pustular, or vesiculo-pustular in expression. Though acute in type, 
eczema of young children is frequently chronic in duration ; a child for 
example of two, three, or four years of age may have had the disease 
in varying degrees and extent since a few weeks after its birth. In 
these persistent cases there may be considerable thickening and infiltra- 
tion of the skin, and periods during which the symptoms are those 
of a subacute or chronic process ; but acute manifestations recur at 
frequent intervals and usually predominate. 

The causes peculiar to eczema of childhood are found in the ease and 
frequency with which the delicate skin is injured by external agents, 
such as soap, hard water, rough clothing, dirt, etc., together with the 
rubbing and scratching that follow pruritus from any cause ; in the 
presence of toxins in the blood, resulting from deficient elimination or 
from imperfect metabolism and assimilation of food, due commonly to 
improper or irregular feeding ; in the so-called reflex irritations arising 
from disorders of the alimentary tract, from dentition, and from other 
systemic disturbances ; and in the local infections of the skin with pus- 
cocci and probably at times with other micro-organisms. That local 
causes are responsible, at least in part, for many cases of infantile 
eczema may be readily inferred from the fact that the disease is com- 
monly limited to, or most severe in, those regions (the face, scalp, neck, 
ears, wrists, and hands) which are not protected by the clothing. In 
other instances the origin of the trouble can be directly traced to the 
irritation produced by some rough article of clothing, or to friction 
and secretion retained between two skin-surfaces, as in intertrigo. Con- 
stipation, overfeeding, or an improperly constituted diet are often the 
direct or indirect causes of eczema. Many fat infants affected with 
eczema improve rapidly after a mere reduction of the carbohydrates in 
their food. Rickets and other forms of malnutrition furnish a skin 
lacking in vitality, and therefore predispose to disease. Catarrh and 



ECZEMA. 357 

other disorders of the gastro-intestinal tract are frequently accompanied 
by eczema, due, seemingly, to reflex irritation. In strumous children, 
adenopathy, furuncles, and conjunctivitis are frequent complications of 
eczema. Rhinitis or otorrhoea often produces a local inflammation of 
the skin, which may spread and persist as a pustular eczema. Sebor- 
rheal eczema occurs as in adults, but in children is more acute, and the 
moist types predominate. According to statistics gathered by Crocker, 
more than one-third of all cases of eczema in children begin during the 
first year of life. 

Success in the treatment of these young patients depends, first, upon 
the painstaking search for, and removal of, the causes ; and secondly, 
upon the care with which the principles of treatment of acute eczema, 
already set forth, are carried out in all details. 

Eczema of the Scalp (Eczema Capitis, Eczema Capielitii). — 
When the scalp is affected with eczema the symptoms differ somewhat 
according to the age of the patient. In adults the erythematous and 
squamous varieties of the disease are more common ; in infants and 
children the pustular variety. In the former the eruption is usually 
circumscribed and in patches ; in the latter it is more diffused. In 
the same proportion, also, the former is generally asymmetrically and 
the latter symmetrically developed. 

In infants and children the pustules rupture early and their contents 
dry into dirty-whitish, yellowish, or greenish crusts, matting the hairs, 
thus serving as foci for dust-accumulation and as nests for lice, the 
crusts being superimposed upon a reddish, oozing, pus-covered, or 
occasionally indolent skin, often foul-smelling, and usually complicated 
by a seborrhoea. The so-called " milk-crust " is usually a compound 
of dried pus and altered sebum. The itching is not so intense as in 
some other forms of the disease. Post-cervical, pre-auricular, and 
occipital adenopathy are common, and in strumous children suppura- 
tion of the affected glands may occur, though this is rare. The causes 
of this form of disease are evidently associated with local conditions. 
The rapidly growing hairs of the scalp are in intimate association with 
the numerous and large sebaceous glands of the same part, which at 
times unquestionably respond by an exudative process to the physio- 
logical stimulus they feel. The acne of the young man whose beard is 
growing illustrates the same fact. Local irritants are not often wanting 
to push the disturbed equilibrium into the scale of disease. White 
calls attention to the common neglect in removing the " pre-natal cap 
of cheesy material," as well as to rude and unskilful attempts to accom- 
plish the same end. Extremes of temperature, friction, excess, neglect, 
and absence of endeavor to wash the scalp, all these contribute to orig- 
inate or to aggravate the disorder. 

The affection when complicated or induced by lice is more common 
in children than in infants, doubtless in consequence of the greater in- 
dependence of the former and their gregarious habits. In girls with 
relatively long hair the ova, or nits, of the parasite are readily distin- 
guished, adhering closely to the hairs and accumulated especially about 
the occipital region. The itching is usually more annoying than in 
pustular eczema not thus complicated. 



358 INFLAMMATIONS. 

The erythematous and squamous forms of the disease, rather more 
common in adults, originate frequently in seborrhcea when scratching 
has been practised or irritant applications have been made. The erup- 
tion here usually occurs in asymmetrical patches, or it may be limited 
to a single patch tolerably well defined in outline, often upon one side 
of the scalp, not, as in infancy, preferring the vertex. Reference is 
made in the chapter on Seborrhcea to a form of eczema of the scalp oc- 
curring in adults in whom finger-nail-sized, circular, oozing or slightly 
crusted patches are generally disseminated over the affected surface. 
They result, as a rule, from the scratching of an obstinate seborrhcea in 
" nervous " women. The reddish friable crusts indicate traumatism, 
the color being due to exuded blood. 

The diagnosis of these forms of disease has been already consid- 
ered. The disorders most commonly confused with eczema of the 
scalp are psoriasis, seborrhcea, tinea favosa, and tinea tonsurans. 

In the treatment of eczema of the scalp in infants and children 
the first indication to be met is the removal of the accumulated 
crusts. When this removal is harshly accomplished it becomes a 
fruitful source of further mischief; it is, therefore, necessary to pro- 
ceed with great gentleness. The thorough softening of the crusts 
is all-important. For this purpose it is necessary to soak them with 
oil and to retain this substance in intimate contact with the scalp. 
Olive- or cod-liver oil may be selected, and, if needful to correct the 
odor or for other purpose, 1 drachm (4.) of carbolic acid may be added 
to each pint (512.), with 2 drachms (8.) of the balsam of Peru. A 
neat-fitting skull-cap, constructed of Lister protective or of flannel, 
should then smoothly be applied, and fastened in place by a light band- 
age, never by elastic-rubber bands. After several hours of soaking 
the crusts should be removed with warm water and spirit-of-soap 
washing, and the entire process be repeated until the crusts are com- 
pletely detached. In selecting an article for subsequent medication 
of the scalp it should be remembered that even infantile eczema will 
proceed to a natural involution if unirritated ; hence oleated lime- 
water, or oil of sweet almonds alone, will often answer better than an 
ointment, and, even where there is considerable acuity of the inflam- 
matory process, lime-water alone, with possibly a small quantity of 
glycerin added, will be effective. In other cases lime-water can be 
medicated better with calomel or with zinc oxide. As the discharge 
and crusting cease ointments instead of oils and lotions may be 
employed. The ointment is to be gently rubbed over the surface with 
the tip of the finger, and the skin afterward protected with suitable 
dressing, such as a gauze-cap. Good ointment-bases for use on the 
scalp are lanolin, vaselin, equal parts of lanolin and oil, or equal 
parts of glycerin, lanolin, and oil. The following remedies may be 
incorporated in strength varying from 1 to 5 per cent. : carbolic, sali- 
cylic, and boric acids ; calomel, white precipitate, ichthyol, sulphur, 
resorcin, and tar. In children and in acute cases strong preparations 
must not be used. When the seborrhceal element is at all pronounced 
the treatment is that of seborrhceal eczema. 

It is rarely needful to cut the hair unless nits be found, though in 



ECZEMA. 359 

public charities it is a more expeditious method of arriving at the 
end when a nurse has to dress the heads of several children in a 
single ward. Lice when present may be destroyed by the application 
of petroleum, bichloride lotions, or alcohol. The nits are removed 
with alcohol or with cologne-water from hairs which it is not desirable 
to cut. In adults, especially in women, the hair should be spared, 
while the patient is warned that the loss of the growth upon the scalp 
may be considerable. Where an obstinate seborrhcea is followed by 
eczema the latter may be succeeded by alopecia ; in the absence of 
seborrhoea the hairs are usually reproduced. It is rarely necessary to 
employ the skull-cap in adults, since one can succeed in insuring the 
necessary applications by directing the attention of the patient to the 
necessity of care and thoroughness. 

As the disease in both classes of patients advances to a subacute or 
chronic stage the treatment may be made more stimulating. In the 
case of infants, however, stimulating topical remedies are very rarely 
to be employed. An eczema of the scalp that has once entered upon 
resolution, in an infant or a child, should generally be soothed and 
protected. 

Many children thus affected are in excellent general health, and 
require no internal medication. The prevailing tendency among the 
laity and even among many practitioners to dose these little ones with 
mercury, arsenic, iodides, and other " blood medicines " cannot be con- 
demned too severely. Frequently, however, the general health needs 
attention. Proper nourishment, elimination, and hygienic surroundings 
should be sought in every case. 

The treatment of erythematous and chronic eczema of the scalp in 
adults is described under eczema seborrhoeicum. 

Eczema of the Face (Eczema Faciei). — Erythematous eczema 
of the face in adults is projected prominently among the varieties of the 
disease by its uniformity of type. It occurs in early and in middle 
life and in advanced years, and is a particularly intractable ailment. 
In well-marked cases the forehead, cheeks, eyelids, and nose of the 
patient are involved, exhibiting an infiltrated, usually dusky-red, often 
symmetrical patch of disease, the affected surface being slightly ele- 
vated above the level of the sound skin. This surface is uniformly 
smooth and reddened ; occasionally, near the root of the nose and 
about the lower line of the forehead minute, closely set papules are 
visible. Very slight oozing, especially after irritation, may be noticed. 
At the height of the disease, or in its involution, exceedingly fine 
scales form, which are scarcely perceptibly shed from the surface. 
The eyelids, especially the lower lids in advanced years, become puffy. 
The line of demarcation of the attacked surface is unusually distinct, 
and rarely invades the scalp-border or the region of the beard. Itch- 
ing is at times intense, the patient bitterly complaining of it and 
usually preferring to rub the face with the hands or with pieces of 
cloth. Sometimes, however, the face is Avell scratched with the finger- 
nails and excoriations and blood-crusts disfigure the countenance. Pa- 
tients of intelligence usually describe the itching as paroxysmal and 
as starting at the root of the nose, wdience it travels upward over the 



360 INFLAMMATIONS. 

forehead and laterally to the brows, often in the line of the supraorbital 
nerves. At the root of the nose the exudative process is most marked. 
The eruption is seen also in asymmetrically disposed patches of various 
sizes, with islets of sound skin between. In typical cases the hairs of 
the eyebrow are reduced to a stubble by constant rubbing. In resolu- 
tion of the symmetrical form this condition of the eyebrows is com- 
monly observed. 

Patients thus affected are often those whose faces have especially 
been exposed to irritation, such as locomotive-engineers, pilots of sea- 
going vessels, mechanics in trades in which the hands are soiled with 
irritants and afterward applied to the face, and women spending hours 
of each day over the laundry-tub or the kitchen-stove. In each class 
the operation of the cause is made manifest by the exacerbation of the 
disease after exposure. 

The affection is most commonly mistaken for erysipelas, a disorder 
from which it is readily differentiated by the chronicity of its course. 
The latter feature is particularly characteristic of this form of eczema, 
which is rarely completely relieved after the age of sixty within a 
twelve-month, and which, when it has existed for a long period of 
time, is particularly obstinate under the best treatment, recurring with 
exasperating frequency upon exposure of the face to atmospheric 
changes. The great vascularity, abundant supply of sensory nerves, 
and necessary exposure of the face explain this peculiarity. In its 
management the lotions and dusting-powders described under the treat- 
ment of acute eczema fulfil an important part. In some cases pastes, 
ointments, plasters, or the glycogelatins give better results than lotions 
and powders. Soothing applications should always be first employed ; 
and more stimulating applications may be tried later. In many cases 
Pick's " linimentum exsiccans " or tragacanth-glycerin mucilage fur- 
nishes a pleasant and effective application. 

In obstinate cases tar and other stimulating remedies recommended 
for chronic eczema should be employed. It is well to remember in the 
management of any case that while a tarry application may be well 
tolerated over one part, as, for example, on the cheeks and near the 
nose, in another part, as, for example, over the eyelids, a zinc-salve 
may better be employed in the same individual. 

In patients of younger years and especially in infants the face is 
likely to display vesicular and pustular phases of the disease, forms 
more often of acute eczema, and correspondingly more manageable. 
The itching, and especially the burning sensations, are prone to be 
severe and crusts rapidly form. In infants the picture presented is 
often similar to that seen in the scalp, except that there are no hairs 
to be matted into crusts and there is often a reddish blush at the 
edge of the patch or where the crust has been removed, the redness of 
the oozing surface being somewhat more marked than the similar 
patches on the less vascular scalp. The scratching in these little 
patients is severe, crusts being torn off in part or wholly ; blood- 
crusted excoriations are common. In this way the area of surface 
involved is clearly extended, sleep is greatly disturbed, and the irrita- 
bility and fretfulness of the child bear heavily upon its general nutri- 



ECZEMA. 361 

tion. In severe cases of long standing the mental tone of the little 
sufferers becomes singularly perverted and their character unquestion- 
ably changed. The eczema of the cheeks and chin of infants is often 
largely due to irritation reflected from eruption of the teeth. 

This chain of formidable symptoms well linked together will often 
bid defiance to the most skilled effort to impart ease to the tormented 
skin. In such cases the harness employed by White, of Boston, fills 
an important office : a skull-cap, made of firm old cotton or linen 
cloth, is closely fitted to the calvarium, and a mask of the same material 
is shaped to the face with exactly placed apertures for the eyes, nose, 
mouth, and ears. This mask is gathered in beneath the chin, and laps 
over two inches at the back of the head ; it may be used only during 
sleep, or, in aggravated cases, also during the hours of wakefulness. A 
species of straight-jacket is made by passing the head of the child 
through a hole in the closed end of a small pillow-case, which is 
then drawn down over the body and arms, and the latter confined at 
the sides by stitching or pinning the case together between the trunk 
and the upper extremities. This jacket is finally secured by similar 
means between the thighs. When it is necessary to imprison the 
lower extremities they are similarly secured by pins within the pillow- 
case ; and the outer edge of such trousers can be fastened to the bed 
or the cushion on which the child reclines. Of course, this treatment 
does not preclude the employment of the washes, ointments, etc., 
which are to be neatly applied next the skin beneath the " trousers" 
or the "jacket." The ointment or other application is thus retained 
in position, rest and protection from all external irritation are given 
to the tormented skin, and its natural tendency to repair soon brightens 
up the case. 

For the treatment of these cases are recommended the black wash 
and zinc-salve treatment, the diachylon salve, Lassar paste, boric acid 
ointment, lead lotions, glycerole of starch, and other preparations and 
methods described in full in the treatment of acute eczema. These 
cases are often very capricious in their course, and treatment may have 
to be changed frequently to meet the varying conditions. 

Eczema of the Lips (Eczema Labiorum). — Reference has already 
been made to the obstinacy of eczema occurring near the mucous out- 
lets of the body, a result due, probably, to the secretion furnished by 
the adjacent mucous tracts. The lips furnish an illustration alike of 
this pertinacity and aggravation. Their frequent motions in mastica- 
tion and articulation aggravate an eczema, which is, moreover, apt to 
be teased by a no less frequent thrusting out of the tongue (where there 
is no beard) to wet the parts with mucus and saliva. Vesicular, pus- 
tular, squamous, and erythematous lesions occur at one point, or along 
the entire line of the lip, with frequently resulting crusts and fissures. 
The vermilion border of the lips commonly participates in the process. 
The lips become hot, and sometimes much thickened by the swelling 
and infiltration, their mucous faces being rarely implicated. Scarlet, 
dull-red, and other peculiarly purplish hues of the vermilion border 
become visible. The parts are more picked than scratched, though 
the itching at times is severe. The pustular and vesicular forms are 



362 INFLAMMATIONS. 

more common in children. The erythematous form, its reddened out- 
line roughened by scales evenly projected beyond the vermilion 
border, is rather an affection of maturer years. In many cases the 
disease is aggravated by nasal discharges which flow over the upper 
lip, giving the latter an elephantiasic aspect or even the appearance 
of an animal's snout. In eczema of the hairy lip the symptoms and 
treatment are those of eczema barbae. 

The diagnosis is between hyphogenous sycosis, herpes labialis, epi- 
thelioma, and syphilis. The first is accompanied by loosening of the 
hairs, caused by a vegetable parasite ; the second is vesicular in lesion, 
brief of duration, and trivial in severity ; the third is a disease of ad- 
vanced years rather than of early and middle life, and is accompanied 
by characteristic induration and ulceration and not by itching. Syphilis 
is fond of the angles of the lips ; in most cases, when thus limited, 
typical mucous patches of the mouth can be discovered. The lesions 
of syphilis at the angles of the mouth are seldom linear fissures, but 
are more often definitely outlined erosions, secreting a puriform mucus. 
Pustules and resulting crusts of the lips and the nose in female children 
are often eczematoid features due to the picking and scratching caused 
by lice upon the scalp. 

In male patients the pipe, the cigarette, and the cigar, as well as the 
tobacco chewed and expectorated, may aggravate the malady. In all 
cases it is obstinate and calls for either emollient, stimulant, or pro- 
tective applications. In eczema of the lips displaying acute and painful 
symptoms frequent fomentations of the part with soft rags dipped in 
hot mucilaginous and alkaline waters will aid in controlling the swell- 
ing and in alleviating the pain. After such bathing some soothing 
ointment should be applied. In chronic cases, in which stimulation is 
demanded, this can be effected at the time of dressing, the parts being 
subsequently protected by collodion or other material. Carbolic acid 
and silver nitrate are often needed for such dressing. 

Equal parts of tincture of benzoin, alcohol, and glycerin applied 
frequently during the day is an excellent combination for the ver- 
milion border. For protecting this portion of the lip cold-cream or 
other simple salve to which has been added enough white wax to make 
as stiff an ointment as can be spread with the finger, is recommended. 
A drachm (4.) of the compound tincture of benzoin with 5 to 20 
(0.33-1.33) grains of tannin may often be added to such ointment with 
good results. 

Cheilitis Glandularis Aposthematosa, Myx adenitis Labi- 
alis. — This is a rare form of chronic inflammation of the lips which 
might be confused with eczema of this region, and which has been 
described by Volkmann, 1 Purdon, 2 and Duhring. 3 

The disease consists in a firm swelling, usually of the lower lip. 
the mucous glands of which are congested and exude a muco-purulent 
secretion,, which dries and forms crusts. There are few subjective 
sensations, but the condition is chronic and rebellious to treatment. 
Duhring states that the condition is usually associated with a depressed 

1 Arch. f. path. Anat. u. Phys., Bd. 1, S. 142. 

2 Brit. Jour, of Derm., Jan., 1893. 3 Cutaneous Medicine, p. 403. 






ECZEMA. 363 

state of the nervous system. The treatment recommended consists in 
warm fomentations, simple lotions, and the occasional use of more 
stimulating preparations, such as alkalies and silver nitrate. 

Eczema of the Nostrils (Eczema Narium). — Eczema of the nos- 
trils is naturally often associated with a chronic coryza. Inasmuch as 
one of the common symptoms of hereditary syphilis is the " snuffles," 
the physician should carefully exclude the possibility of such disorder 
in every instance when an infant with coryza exhibits an " eczema " 
of the nares or of the lips. The age of the little patient, an inspection 
of its anal region (which should never be omitted in infantile eczema), 
and the history of the case will throw considerable light upon this 
important question. 

Whether occurring in the adolescent or the child, the disease may 
linger only upon the alee in the pustular or the squamous form, or may 
block up the nares with crusts. In infants this obstruction enforces 
respiration with an open mouth, and the grasp of the nipple by the 
lips is thus interrupted either by respiratory acts or cries of agitation. 
The Schneiderian membrane participates in the inflammatory process 
and pours out its secretion upon the eczematous skin. This membrane 
when inspected is seen to be either raw and succulent, or in a condition 
analogous to that seen in pharyngitis sicca, is dry, glazed, and free 
from discharge. The nostrils are often thickened in consequence of 
infiltration or are fissured, especially at the lines of the nares, laterally 
and inferiorly. In severe cases, and when the lips participate in this 
process, the pouting, swollen, and distorted organs suggest the snout of 
the lower animals. Adults, as a result, frequently suffer from cocco- 
genous sycosis and furunculosis. 

Care should be taken to exclude syphilis in making a diagnosis, 
bearing in mind the fact that the pustular syphiloderm (which see) fre- 
quently selects the furrow on either side of the nostrils for its evolution. 

In treating these cases all crusts should be removed and the parts 
carefully be protected. Picking of the nose in children should be 
prevented, if needful, by the " straight-jacket." Pencillings with com- 
pound tincture of benzoin, iodized phenol, silver nitrate, or collodion 
often prove serviceable. 

In softening crusts oil may be freely used. For this purpose the 
warm carbolized oil-spray of the atomizer or a glycerin-lotion answers 
well. After softening and removal of the* crusts a simple ointment 
containing from 5 to 20 grains (0.33-1.33) of boric acid, or from 2 to 
10 (0.13-0.66) grains of white precipitate to the ounce (30.) may be 
used. A weak citrine ointment is often serviceable. When the dis- 
ease extends well up the nares Neumann employs bougies made by 
combining 2 grains (0.133) of zinc oxide with 16 grains (1.06) of 
cocoa-butter. Hardaway recommends equal parts of cold-cream salve 
and glycerole of lead subacetate. 

Eczema of the Ears (Eczema Attritjm). — The ears are affected 
with eczema, both in infancy and maturer years, rather more often in 
women and children, the disease being limited to the whole or part of 
the organ, or extending backward over the post-auricular region, or 
downward over the ramus of the superior maxilla. The eczema may 



364 1NFLA MM A TIONS. 

be acute or be chronic, and commonly originates in seborrheic eczema 
(which see) of the scalp or the face, but may find its origin in chronic 
or catarrhal discharges from the external auditory meatus ; in the 
growth of aspergillus in the same canal ; in exposure to temperature- 
changes, especially with high winds ; in frostbite ; in the irritation set 
up by pediculi and by the auricular rim of the frame of spectacles ; in 
the toxic effect induced by the hook of cheap ear-rings and dyed bonnet 
ribbons ; in the traumatism of ear-piercing ; and in the habit of unnec- 
essarily picking the ear to relieve it of wax or of trifling sensations of 
irritation. 

The pustular and moist forms are common at the superior, inferior, 
and posterior boundaries of the pinna, where a linear fissure is liable to 
form in the line of the angle made by the auricle with the plane of the 
adjacent integument. The motions impressed upon the ear by handling 
it, or by placing the hat on the head and tying hat-strings over the ear, 
always tend to aggravate the disorder. Long hairs worn over the ears 
have a similar effect by the production of friction and the retention of 
heat. The lobules are likely to display the erythematous and scaly 
phases of eczema, becoming infiltrated, and having a deformed appear- 
ance and lurid-red color, the affection pursuing an indolent course. 
The lobules alone of both ears in young women may similarly be 
affected, and may exhibit these phenomena for consecutive years. Often 
the chronic inflammation lays the foundation for a keloid growth, an 
accident of inflammatory processes in other parts. 

Sometimes the entire auricles are uniformly dark red, infiltrated, 
alternately weeping and scaling, and project to a noticeable extent from 
the side of the head in consequence of their increase in bulk. The 
itching is usually more annoying than severe, being accompanied by a 
characteristic sensation of tenseness and fulness of the part. Like the 
eczema which occurs at the other mucous outlets of the body, the affec- 
tion in the meatus is particularly obstinate when it assumes a chronic 
form. Symmetry to the extent of involving both ears, though com- 
monly to a different degree in each, is rather the rule than the exception, 
and is doubtless due to the simultaneous operation of effective causes. 

The diagnosis is between erysipelas, seborrhea (which occasionally 
occurs in the concha of the auricle), erythema simplex and multiforme, 
and dermatitis calorica. 

The treatment should at first be soothing and protective by zinc salve 
or diachylon ointment or by soothing and astringent lotions ; afterward 
it should be stimulating. A firm bandaging of the ears to the head 
may be required to support them, to prevent irregular pressure (of the 
head upon the pillow), and to retain external medicaments. In chronic 
cases stimulant applications are often well tolerated, and sulphur, 
salicylic acid, ichthyol, and tar ointments here play an important 
part. Treatment appropriate to the otitis externa or the aspergillus 
may be required. Bulkley recommends a tannin ointment, 1 drachm 
(4.) of tannin to the ounce (30.), deeply and thoroughly passed into 
the meatus on a camePs-hair brush. French authors generally advise 
small tampons smeared with an ointment and left in the canal 
Burnett employs 2 drachms (8.) of oil of tar to 1 ounce (30.) of al 






ECZEMA. 365 

cohol. Great benefit is derived from painting the indolent surfaces 
with solutions of silver nitrate. The intractable forms almost invari- 
ably affect adults, in whom there is usually a history of improvement 
under treatment, followed by relapse due to exposure to wind, heat, 
cold, or other sources of irritation. Many cases require the treatment 
recommended for eczema seborrhoeicum. 

Eczema of the Eyelids (Eczema Palpebrarum). — In eczema of 
the eyelids the free edges of the eyelid, or the skin over the orbital 
margin of the tarsal cartilage, may chiefly be affected ; and these parts, 
both in children and adults. When the free edge of the eyelid is in- 
volved there is present a species of coccogenous sycosis, the hair-folli- 
cles becoming inflamed and furnishing a purulent discharge which may 
agglutinate the eyelids. The latter are thickened and swollen, become 
the seat of a moderate itching, are picked rather than scratched, and 
exhibit minute crusts between, or glued to, the hairs. The disorder is 
often accompanied by a seborrhoea of the Meibomian follicles, and is 
described by oculists under the designation of " blepharitis " or " tinea 
tarsi." Inasmuch as the facial expression is characteristic when 
the eyelids are thus involved, patients exhibiting this form of eczema 
are usually set down as " scrofulous/' though the disorder occurs in 
many individuals with no other sign of struma, and eczema surely is 
not such a sign. 

Fissures occasionally form at the commissure of the eyelids. The 
disorder may complicate eczema of other parts of the face. In erythe- 
matous eczema faciei of adults there is usually swelling with puffiness, 
especially of the lower eyelid. The conjunctiva may or may not be 
implicated. A chronic granular condition of the eyelids is not noted 
as frequently as might be suggested by a priori reasoning. 

The edges of the eyelids should carefully be cleansed with a weak 
alkaline solution and a soft camel's-hair brush whenever the eyelid is 
involved, and then as carefully be dried and anointed with cold-cream 
salve. In acute cases the closed eyelids may be bathed frequently 
with warm solutions of boric acid or of borax (1 to 2 drachms [4. to 
8.] to the pint), and strips of soft lint, soaked in the same solution, 
or a very dilute glycerin and carbolic acid lotion may be laid over the 
closed lids for as long periods during the day as these remedies are 
comfortably tolerated. In chronic cases red mercuric oxide ointment, 
from 1 grain to 10 (0.066-0.66) to the ounce (30.), with or without an 
equal quantity of salicylic acid, is held in high esteem. Oculists, in 
the treatment of this affection, are fond of using an ointment of yellow 
mercuric oxide, 1 to 3 grains (0.066 to 0.2) to the drachm (4.). In 
place of these mercurials the unguentum hydrargyri nitratis, 1 part to 
6 of cold-cream salve, may be applied, or resorcin 1 part to 100 of 
simple unguent. Epilation of the eyelashes may be necessary. Pen- 
cillings with solutions of silver nitrate in various strengths are also 
useful in chronic cases, but these solutions must carefully be confined 
to the eyelids, and not be suffered to come in contact with the con- 
junctiva. Excessive use of the eyes must be prohibited. 

In the diagnosis care must be taken to exclude syphilis, lupus, and 
pediculi. Piedra of the eyelashes must not be overlooked. Instead 






366 INFLAMMATIONS. 






of the ordinary nits of the lash, there are in such cases jet-black, pin- 
head-sized masses of ivory-like hardness attached to the hairs. 

Eczema of the Beard (Eczema Baeb^:). — Eczema may involve 
the region of the beard only, or it may exist in connection with the 
disease on other parts of the face. 

In recent cases there is no loss of hair, but in those of long standing 
the hairs are thinned and fail to hide completely the reddened surface 
beneath, covered here and there with pustules or displaying floors of 
broken pustules, dried inflammatory products, yellowish and greenish 
scales and crusts. Beneath the crusts the surface is smooth, not lumpy 
as in hyphogenous sycosis. The hair-follicles are not solely involved, 
as in the coccogenous form of that disease, but evidently they and also 
the integument between them are inflamed. In chronic cases the symp- 
toms may be those of erythematous and scaling eczema. In recent 
eczema the hairs are not loosened in their follicles, but in chronic cases 
such loosening does occur, and there is a true defluvium capillitii. 
The disorder is one primarily involving the skin, and secondarily the 
hair-follicle, extending smoothly over the surface, as smoothly as an 
eczema on the cheek of a woman. There is commonly a certain 
degree of symmetry, to the extent at least of involving the beard in 
different degrees on both cheeks at once, or the chin on both sides ; 
often the symmetry is perfect. This symmetry is rare in the several 
sycoses of the same part. 

The disease is accompanied by itching, rarely so severe as upon the 
smooth parts of the face, is particularly obstinate, and is extremely 
disfiguring. When extending into the region of the beard from other 
parts it is usually associated with eczema of the ears. When limited 
to the region of the moustache it may be connected with an eczema 
of the nares and a chronic nasal catarrh or be a symptom of seborrheic 
eczema. 

The condition is more superficial than that of hyphogenous sycosis 
and never shows any of the deep-seated nodules found in the latter 
disease. From coccogenous sycosis it is differentiated with greater dif- 
ficulty, as the two conditions have many features in common. Sycosis 
is primarily an inflammation of the hair-follicles, a distinct folliculitis, 
and presents a characteristic pustule pierced by a hair at the mouth 
of ,the follicle. In this disease there are also found papules and small 
tubercles. Though there is a superficial inflammation of the follicle 
in eczema of the beard, a distinct folliculitis is not present and there 
are no papules or tubercles. Moreover, the skin-surface between th 
follicles is evenly involved in eczema, while it frequently escapes wholly 
or in part in sycosis. Eczema quite commonly coexists on other por- 
tions of the face, while sycosis is limited strictly to the region of the 
beard. 

The treatment of recent cases of eczema of the beard is that of sim- 
ilar phases of the disease on other parts of the body, by means of the 
simpler lotions and ointments, but cases of long standing are exceed- 
ingly stubborn and frequently require vigorous measures. After remov- 
ing crusts and other accumulations by soaking with oil and thorough 
washing with soap and water the beard must be wholly removed. 






ECZEMA. 367 

Clipping short the hairs of the face will not answer, though this is 
generally preferred by the patient as exposing to a less degree the 
unsightly surface beneath. Nothing short of epilation or of shaving, 
and repeated shaving every second day, Avill effect the desired result 
in chronic cases. As soon as the disease is reduced practically to an 
eczema of the non-hairy parts it improves in proportion to its distance 
from the mucous outlets of the body. When limited to the bearded 
cheeks the most obstinate cases in the course of a single month may be 
robbed of one-half their unsightliness. The patient should be encour- 
aged by reminding him that usually it is but the first step which costs, 
each succeeding removal of the beard being accomplished with greater 
comfort to himself physically and mentally. After each shaving the 
skin should be bathed with water as hot as tolerable, and, if at night, a 
lotion or an ointment, or the latter after the former, may be used. The 
salves most useful for this purpose are sulphur, 10 to 60 grains to the 
ounce (0.66-4. to 30.); diachylon ointment with salicylic acid, 5 to 10 
grains to the ounce (0.33-0.66 to 30.), and zinc or tar ointment. 
Rarely, the surface requires painting with weak solutions of silver 
nitrate. As the condition improves a dusting-powder will afford 
needed protection during the day. The shaving should be continued 
for months after the disease is at an end. 

Eczema of the Genital Organs (Eczema Genitalium). — In 

1 eczema of the genital organs the disease is remarkable for the severity 

I of the subjective sensations it occasions; for its tendency to persistence, 

I recrudescence, and nocturnal exacerbation ; and for the liability to the 

1 production of the sexual orgasm by the act of scratching. In men the 

surfaces most often involved are the anterior, the posterior, or lateral 

faces of the scrotum where they meet the thigh, though the surface of 

' the penis, as also that of the pubes and the perineum, may be involved. 

In women the labia majora, more rarely the labia minora and vestibule 

of the vagina, are affected, with occasionally extension of the disease to 

the same contiguous parts as in men.- 

Eczema thus located is, as a French Avriter has well said, "a dry 
disease in a moist locality." Vesicular and pustular forms are much 
I rarer than the erythematous, the papular, the papulo-squamous, and 
\ the erythemato-squamous. In women the moister forms are more 
I frequent, doubtless because of the wider mucous outlet and the more 
I extensive mucous tract in the vicinage. The labia are then heightened 
jin color, oedematous, agglutinated by crusts, and often torn viciously 
by the finger-nails. Blood-crusted excoriations are seen in most of the 
I severe cases. An eczema intertrigo at the labio-femoral angle is com- 
t mon. Over the whole may be poured the normal or pathologically 
altered secretions from uterus or vagina. The disease, however, is suf- 
ficiently common after the menopause, when there is usually physio- 
k logical atrophy of the uterus. 

The typical disease in men is recognized in the thickened, reddened, 

perhaps slightly scaling integument of the scrotum, which may also be 

fissured, excoriated by the finger-nails, or covered with blood-crusts. 

[(Torn papules, even tubercles and nodose swellings may be closely 

packed together, exhibiting a lurid or even purplish hue. In aggravated 






368 INFLAMMATIONS. 

cases the infiltration is so great as to deform the parts, increasing the 
thickness and deepening the normal furrows of the scrotal integument 
to the grade of many times its normal dimensions, producing thus an 
elephantiasic appearance. In eczema of the penis also the prominent 
symptoms are oedema, itching, and redness with slight scaliness. 

In both sexes, as before indicated, attempts to relieve the itching are 
often as severe and prolonged as they are ingenious. Commonly no 
relief is obtained until a serous sweating or weeping of the thickened 
tissues is induced by the friction. Inasmuch as the latter in severe 
cases is frequently repeated, the physical dangers are obvious. 

Apart from this, however, the disorder has a marked tendency to 
disturb the mental tone and the general health. Shame deters many 
from seeking speedy relief, so that cases of long standing are often 
registered by the physician. Though unconnected with venereal dis- 
ease of any kind, there is for many a special dread of an eczema of 
these parts simply because of its location. With sleep disturbed, the 
mind agitated, and the nervous system teased by an intolerable pru- 
ritus, one can scarcely wonder at the eloquence with which many 
patients describe their sufferings. It is a disease of middle life and of 
advanced years. It is rare to see a well-marked, obstinate case in a 
child. 

The causes, exciting and aggravating, of eczema of the genital region 
are often obscure, but undoubtedly depend largely upon heat, moisture, 
and friction. These factors are favored — first, by the effect of gravity, 
the organs in question being situated, when the body is in the erect 
position, at the inferior apex of the double cone forming the trunk and 
being thus subject to the force of gravity ; second, by the arrangement 
of the clothing in both sexes, by which heat and friction-effects are 
heightened ; third, by uncleanliness, the secretions and discharges from 
the adjacent mucous tracts being suffered to accumulate upon the person. 
The cause may lie in some disturbance of the genital organs or of the 
general nervous system. In some cases the disease is apparently reflex 
in origin. 

In many eczemas of the surface, and especially those of the genital 
organs, the urine will be found to contain albumin or sugar, and these 
conditions have been supposed to lie at the root of the eczema. The 
diet of the eczematous patient with saccharine urine is of prime impor- 
tance. In some cases, however, the eczema causes the elimination of the 
sugar or the albumin, and not the reverse. Sugar and albumin are 
known to be producible in urine by external irritants, among which are 
cutaneous diseases. Merely varnishing a portion of the skin has been 
followed by these effects. If a patient with saccharine urine and severe 
genital eczema can be kept in bed in the recumbent position for a few 
days, while any soothing application productive of comfort is continu- 
ously applied to the tender and excoriated surface, the sugar will often 
rapidly disappear from the urine. These renal symptoms are in part 
reflex, resulting from the extraordinary irritation of the nerves distrib- 
uted to the involved surfaces. Many cases of extensive and severe 
eczema of the genital region in both sexes occur in patients in whom 
careful and repeated examination of the urine fails to reveal sugar, 



ECZEMA. 369 

but the practitioner is urged never to omit such examination in his 
treatment of a typical case. 

Patients exhibiting genital eczema with glycosuria may be separ- 
able into two distinct classes. The first and commoner class includes 
those patients presenting such marked physical symptoms that the urine 
may be suspected before chemical examination. These patients are 
extremely fleshy men or women given to an excessive consumption of 
beer. In such patients the sugar decreases pari passu with the eczema, 
if the beer is withheld and the local irritation is judiciously treated. 
In a second and much graver class of patients, chiefly women, there is 
a diabetic history (often also of pulmonary tuberculosis), and the gen- 
ital eczema is manifestly an epiphenomenon. These patients are rarely 
obese, usually the figure is that of a slender and delicate woman ; there 
is little, if any, use of alcoholic beverages and the local eczema is trifling 
in features as compared with that in the class first described. In these 
cases, too, under the influence of an appropriate dietary and local man- 
agement the genital eczema subsides, but the glycosuria persists often 
to a grave issue. Genital eczema occurring with glycosuria is one of a 
group of disorders named by French authors Diabetides Genitales. 

The diagnosis of eczema of the genital organs is between ringworm, 
acne, pruritus, pediculosis, the venereal disorders, and herpes progenita- 
lis. The first-named affection may occur alone or may induce or may 
be grafted upon the eczema. Ringworm may be recognized by the dis- 
covery of the microsporon or trichophyton, and is clinically distin- 
guished by the crescentic edge of the spreading patch, its convex border 
looking away from the genital centre. The " follicular vulvitis " of 
gynaecological authors is a genital acne and is manifestly limited to the 
glands and the periglandular tissues. The same is true of bromine and 
iodine acne, Avhich may be developed in the same situation in both sexes. 
Genital pruritus may beget an eczema from scratching, but it is accom- 
panied primarily by no skin-lesion. The pubic louse is visible to the 
eye, as are also its reddish excreta and nits. The ulcers and sclerosis 
of chancroid and primary syphilis are rarely accompanied by pruritus, 
and, though occasionally multiple, never exhibit diffuse patches of dis- 
ease. Syphilodermata are recognizable by their characteristic features 
and the history of an infectious disease. In herpes progenitalis there 
i are precedent burning, smarting, or neuralgic sensations, the occurrence 
of vesicles or groups of vesicles (lesions rare in eczema of the genitals), 
and frequent limitation of the disorder to the mucous surfaces or to the 
muco-cutaneous lip by which such surfaces are bounded. In eczema 
these boundaries are usually respected and the disease is much more 
strictly cutaneous. 

The treatment is to be conducted on the general principles hereto- 
fore outlined. Sponging of the genital region with alkaline water 
as hot as can well be tolerated, followed by the blander lotions, oils, and 
ointments at night, and the use of antipruritic dusting-powders in the 
daytime, must not be omitted. One per cent, solutions of formalin are 
of value. In eczema of the scrotum a suspensory bandage lined with 
lint which is wet with a lotion, smeared with an ointment, or thoroughly 
covered with a powder, can usually be employed with advantage. 

24 



370 INFLAMMATIONS. 

The habit of scratching must be broken up at all hazards. In chronic 
cases treatment by soft soap and diachylon ointment will be found 
useful. Caustics, solutions of mercuric chloride and other mercurials, 
carbolic acid, and especially the tarry compounds, are often necessary. 
The Lassar paste also may be used with advantage. 

The following formulae are useful in allaying the irritation of some 
acute and subacute cases : 



R Liniment, calcis, f ^iv; 120 

Belladonn. extr., gr. xij ; 

Zinci oxid., 3ij ; 8 

Glycerini, f.^ij ; 8 

Aq. calcis, f giv; 120 



80 



M. 



Sig. Lotion to be applied at night after bathing the parts with hot water. 

R Liniment, calcis, f giv; 120 

Acid, hydrocyanic, dil., f^j; 4 

Liq. plumbi subacetat., f^ij ; 8 

Glycerini, f £ij ; 8 

Aq. ros., adf^viij; 240 M. 
Sig. Cream, for application on strips of old linen. 






Exceedingly obstinate eczema of the pubic region is benefited by 
shaving and subsequent appropriate treatment. When complicated by 
intertrigo the latter condition requires special relief by the interposition 
of soft lint spread with an ointment. 

Eczema of the Anus and Anal Region (Eczema Ani). — Eczema 
of the anal region, in its etiology and characteristics, is closely allied 
to the same disease in the genital region. The presence of ascarides 
and hemorrhoids occasionally induces or aggravates the disorder ; 
though this complication is rarer than is commonly supposed. Multi- 
tudes of men and women who suffer from piles never complain of 
eczema. The eczema may occur in erythematous, squamous, or papu- 
lar form, in the order named ; thus exhibiting here, as in the genitals, 
" a dry disease in a moist locality." 

The redness, infiltration, and itching may be limited to the verge of 
the anus, radiate from the latter in stellate lines, creep upward between 
the nates in the cleft, sweep forward over the perineum to the genital 
region, or extend laterally with intermediate intertrigo over the inner 
face of each thigh. Rarely the buttocks are covered with the same 
lesions. Fissures are likely to form about the anal orifice. 

This disease is common in infancy, when want of care in the removal 
of the napkin is a fertile source of mischief; and also in persons in mid- 
dle life and in advanced years, when it becomes particularly intractable. 
The itching is intense in the latter class, with frequent nocturnal exacer- 
bation. Unfortunately the scratching is often reflex, and is practised 
during sleep, from which the patient is often aroused by his or her 
manipulations. Pollutions fully recognized, or occurring during pro- 
found sleep, or, more usually, in states of semi-consciousness, compli- 
cate certain cases ; defecation becomes painful ; the harassed nervous 
system of the sufferer is often in a deplorably wretched condition. 
In cases of long standing the usual congested, thickened, infiltrated, 



ECZEMA. 371 

and almost elephantiasic appearance of the skin is presented, with 
occasional fissures and exaggeration of the natural furrows. The part 
may simulate in aspect the formidable conditions discovered in passive 
pederasty. Excoriations are common around the anal verge. 

In the treatment of these cases the use of very hot water by 
sponging, and the subsequent application of ointments, in some 
cases mild but in others stimulating, have yielded the best results. 
In the case of infants dusting-powders and the blander ointments 
are alone to be employed ; in adults, especially in chronic cases, tar 
in some form is especially valuable. Here the Lassar paste may be 
applied or tincture of tar be freely painted over the surface, or there 
may be used one of the tarry ointments, such as the Wilkinson salve, 
of sufficient firmness to retain its form as an unguent when sub- 
jected to the heat of the part. Caustics, especially the silver nitrate 
in crayon, are useful when there are fissures. Corrosive sublimate, 
J to ^ of a grain (0.016-0.033) to 4 ounces (120.) of milk of almonds ; 
Squire's glycerole of plumbic subacetate, J drachm (2.) in 2 ounces 
(60.) of glycerin and water, or, as a substitute for the latter, soft soap 
and diachylon plaster, are here of special service. Almond-oil, or an 
ointment containing 2 to 10 per cent, of carbolic acid, often gives 
relief. Duhring recommends the following : 

R 



Sulphur, preecipitat., 


9y; 


2 


m 


Naphtol. , 


Ed; 


1 


33 


Morph. acet., 


gr.ij;] 




133 


Zinci carb. , 


3j; 


4 




Ungt. aq. ros., 


ij; 


30 





M. 

When defecation is painful the stools should be semiliquid in order 
to insure non-aggravation of the local disorder, not, it need scarcely 
be remarked, with a view to eliminating any materie.s morbi by purga- 
tion. Small tampons of cotton may be smeared with an emollient oint- 
ment and gently be inserted for a short distance within the anus. 
Tincture of benzoin, 1 part to 8 of vaselin, may be used for this pur- 
pose. Kaposi recommends cocoa-butter suppositories, containing zinc 
oxide with belladonna or opium. When complicated by true fissure 
of the anus the sphincter ani must be stretched or divided, or dilated 
with medicated bougies. At night a cataplasm is applied. The parts 
are washed frequently with tepid water, and the anal tampons are 
smeared with cocaine. During the day zinc oxide salve, 30 grains (2.) 
to the ounce (30.) of vaselin, is applied, and over this are thoroughly 
sprinkled equal parts of zinc oxide and bismuth subnitrate in fine 
powder. Collodion medicated with 1 to 3 per cent, of salicylic acid, 
and lotions containing 1 scruple (1.33) of silver nitrate to the ounce 
(30.), are of great value in many cases. Besnier recommends the use 
of a clyster after each bowel-movement, the fluid being retained for 
only a short time. Pencillings of fissures with crayon of silver nitrate 
are indispensable in severe cases. 

Veiel prefers the cautious use of chrysarobin to tar, employing the 
latter either in the form of spirits or as tar-diachylon, 1 part to 20, 
gradually increasing in strength. Carbolic acid, 1 to 5 per cent., and 



372 INFLAMMATIONS. 

glycerin, 2 to 10 per cent., in elder-flower water or in almond-emulsion, 
are specially indicated in fleshy women when the disorder, as is often 
the- case, is complicated with intertrigo. 

The key to most cases of anal eczema is to be sought in the dietary. 
This disorder, in adults particularly, is likely to be a significant symp- 
tom of gout, and without the dietetic and medicinal treatment of that 
condition no local applications avail. Tobacco and alcohol are invari- 
ably to be excluded in the case of patients of this class ; and blue pill, 
alkalies, colchicum, and salicylates are often needed. It is in these 
manifestations of eczema that health-resorts furnish their best results, 
necessitating and inviting, as they often do, an out-door life, an appro- 
priate regimen, and an avoidance of stimulants. Even in children and 
infants, when there are no ascarides in the rectum or the vulva, the 
dietetic management of the patient should never be neglected. 

Eczema of the Nipple and Breast of Women (Eczema Mammje). 
— Eczema of the mammary region is common in nursing-women either 
from the irritation produced by the mouth of the infant, or, more 
commonly, in consequence of a galactorrhea. Eczema intertrigo is 
common below and between the breasts. The eczema here is vesicular, 
erythematous, or squamous in type, with fissures at the apex, the side, 
or the base of the nipple. The serous ooze from the infiltrated areas 
dries as usual into light-colored crusts. There are the characteristic 
burning and itching. The disease may occur on one or both breasts, and, 
especially with a galactorrhea in the summer, may spread extensively, 
covering both breasts, the surface of the belly, and the intermammary 
region. The circumscribed forms occur also in pregnant or in unmarried 
women, and are to be distinguished from scabies, which in women is 
prone to occur upon the breast. 

Paget's Disease, which in its early stages presents all the appear- 
ances of an eczema, is more fully described in this treatise among the 
epitheliomata ; it is sufficient here to call attention to the important 
fact that a fairly well-defined eczematoid patch, surrounding the areola 
of the nipple or that organ only, with infiltration, itching, and possibly 
a fissure of the nipple, or a crust covering a superficial erosion, may be 
the sign of an epitheliomatous change already advanced either in the 
affected part only or deeper in the galactiferous ducts of the breast itself. 

The treatment of mammary eczema is that of eczema in general. 
In severe cases with galactorrhea nothing short of weaning the child 
and a cessation of all demands upon the breast will insure relief. Every 
effort should be made in milder cases to avoid this dernier ressort. The 
nipple should be thoroughly cleansed after each nursing. As a rule, 
hot water and soap may be used for the purpose without harm and 
usually with benefit. Any fissures existing should be then painted 
with compound tincture of benzoin, tincture of myrrh containing 1 
grain of mercuric chloride to each ounce (0.06 to 30.) or weak solutions 
(2-15 per cent.) of silver nitrate. The whole should immediately be 
covered with a protective ointment or paste. The zinc oxide or dia- 
chylon ointment spread on lint serves the purpose well. Salicylated 
and borated pastes are sometimes preferable. Lister's borax salve often 
does well : 

. 



ECZEMA. 373 

R Acid, boracic. subtil, pulv., | 

Cerae alb., j G ' 

Paraffin., 

01. amygdal., 



} aaSss; aa 2 



M. 



In some instances stronger and more stimulating remedies are 
necessary. Before the child takes the breast all but the simplest 
preparations should be entirely removed with oil or other unirritating 



agent. 



Fournier recommends a breast-plate of caoutchouc. When the 
disease is limited to the nipple and areola in nursing- women the glass- 
and rubber-apparatus sold in the shops may be tried in the hope of 
saving the nipple from mouth-contacts in nursing. Sometimes they 
answer admirably ; often they utterly fail. Dusting-powders are valu- 
able in mild cases, and for any intertrigo that may exist between and 
beneath the breasts. 

Eczema of the Umbilicus (Eczema Umbilici). — This local variety 
of the disease is briefly described in the chapter devoted to Seborrhoea. 
In most cases it is either induced or is aggravated by a seborrhoea fluida 
which gives origin to the peculiarly nauseating odor characteristic of 
the disease. Generally a reddish and infiltrated, more or less annular 
patch surrounds the umbilical depression, which may be filled with 
1 crusts. Syphilodermata, pediculosis, and scabies in women are to be 
carefully excluded in the diagnosis. 

Liquor sodae chlorinatae, carbolic acid solutions, and, in chronic cases, 
iodized phenol will be required in its management. The dressing of 
the navel in the newborn infant, the improperly adjusted apparatus 
for retention of an umbilical hernia, and the corsets or " uterine sup- 
porters " of women, should not be permitted to occasion or aggravate 
the disease. 

Anderson reports that in typical cases, especially of those affected 
with scabies, the navel is swollen and projects in the form of a small 
tumor. 

Eczema Orurum (Eczema CrueAle). — Upon the legs, where the 
force of gravity is more potent than in other parts of the body, aggra- 
vated forms of eczema are found complicated with varicose veins and 
oedema, with dense infiltrations and indurations. In ancient cases the 
frequent elephantiasic aspect is significant, one limb being several 
inches larger in circumference than its fellow. The skin is covered 
from knee to ankle with enormous patches of eczema rubrum of an in- 
tensely angry appearance, moist and crust-covered ; or is dry, glazed, 
and of a lurid, reddish hue ; or is dry, horny, and ridged with irregular 
projections surmounted by scales resembling the rough bark of a tree ; 
j or, again, with or without oedema, the integument is tense, inelastic, 
seamed with scars of old varicose ulcers, and deeply and irregularly 
pigmented, a condition with some difficulty distinguished from syphi- 
litic ulceration of the same region. At its onset eczema of these parts 
may assume any one of its known forms. In infants in long clothing, 
where the lower extremities are subjected to a higher temperature than 
in adults, the vesicular and pustular forms are common. The exceed- 
ingly obstinate forms of eczema of the legs, especially those complicated 



374 INFLAMMATIONS. 

with varicose veins, are, of course, chiefly encountered in middle life 
and in advanced years. 

The diagnosis is, in general, to be established by considering the 
points heretofore discussed. The chief difficulty lies in distinguishing 
the eczema associated with ancient varicose cicatrices of the leg from 
syphilitic scars of the same locality that have resulted from degener- 
ating tubercular syphilodermata or from gummata. In some cases, when 
no distinct history can be obtained, there will be a doubt, since the 
force of gravity upon the vessels, even without varicosities, produces 
certain common features, notably deep pigmentation, in both classes 
of cases. In women the sexual history is all-important, including the 
order of succession of abortions, miscarriages, and viable infants. In 
both sexes the discovery of other lesions, and especially of character- 
istic cicatrices elsewhere, must be attempted. It will be remembered 
that the syphilitic ulcer tends to the shape of a circle or a segment of 
a circle, and though occasionally existing as the sole lesion upon one 
leg, it is frequently multiple, or may involve both extremities, the pig- 
mentation in old cases occurring chiefly at the periphery of the scar. 
Very extensive pigmentation about ancient cicatrices, especially dis- 
posed between irregularly defined scars, is commoner in eczematous 
forms, as the pigmentation due to syphilis though long-lived is yet the 
more ephemeral. With periosteal nodes the diagnosis is clear. 

The treatment of eczema of the legs does not differ from that of 
eczema in general, except as regards the indications to be met rela- 
tive to the support of the parts, thus counteracting the effect of 
gravity. In severe cases rest with the foot elevated and the leg placed 
in the horizontal position should be maintained, and other indica- 
tions met by the use of the various liniments, lotions, and ointments 
already described. For those who must pursue their accustomed 
occupations the problem is difficult. An excellent preparation for 
subacute and chronic cases is found in the glycogelatins, as they 
furnish not only protection, but also some support. Moreover, they 
frequently may be left in position for a week at a time. As a rule, 
they are not indicated in acute cases or where there is much discharge ; 
yet in some of these cases they are well tolerated and do good. A 
moderately firm paste is made by taking 30 parts each of white gelatin 
and zinc oxide, 40 parts of glycerin, and 90 parts of water. The 
method of preparation has been given in the preceding pages. From 
1 to 3 per cent, of ichthyol, thiol, or salicylic acid in most cases may 
be added with advantage. 

A dressing well adapted to the larger number of cases of eczema 
of the lower limbs is disinfection of the surface and the application of 
the Lassar paste or other well-selected unguent or paste, followed by 
dusting the whole area with a powder, over which may be neatly 
applied, if desirable, a cheesecloth bandage. Often, however, this band- 
age may be dispensed with, as in both sexes a woman's long stock- 
ing, made light and thin, such as is used in the summer season and 
always of white or undyed cotton, may be drawn over the limb. 
Over this stocking may be wound, for the purpose of support, either 
a flannel bandage cut on the bias, which can, as a rule, be applied 



ECZEMA. 375 

without especial skill by the inexpert, or in chronic cases that will 
tolerate it an elastic bandage, the inner white stocking being changed 
with each dressing. In the case of male patients it is often desirable 
that the man's " sock " be drawn over the long white stocking below. 
In this way support without compression (which is the essential point) 
may be secured. 

Excellent results may be obtained by the use of the pure rubber 
bandage, applied immediately next the skin, especially in cases compli- 
cated by oedema, ulceration, and venous varicosity. The method of its 
application is generally familiar to the profession. The starch bandage, 
the plaster-of-Paris dressing over folds of Canton flannel so arranged 
that it may be removed at will in the manner in which it is used by 
some surgeons in treatment of diseases of the joints, these and other 
immovable dressings may accomplish even more in obstinate cases than 
elastic apparatus. 

A favorite dressing in dry, papular, erythematous, and squamous 
patches of the disease is applied as follows : the parts are bathed 
with hot borated water for several minutes until the itching is relieved, 
and then are carefully and thoroughly dried. The patch is then com- 
pletely covered with a dusting-powder, which, according to the indica- 
tions of the case, is either emollient, astringent, or stimulating. Finely 
powdered tannin with French chalk, or boric acid and starch, or bis- 
muth subnitrate, zinc, and starch may thus be used. Strips of cheesecloth 
are superimposed. A snug-fitting rubber or flannel bandage cut on the 
bias encompasses the whole. The dressing is left £71 situ as long as it 
is comfortable, often for two or three days, when it can be removed. 
In properly selected cases the itching is relieved, the infiltration is 
reduced, and the patch soon loses its hypersemic aspect. Occasionally 
no other treatment will be required. 

Eczema of the Hands and the Feet (Eczema Manuum, Eczema 
Pedum). — No more striking illustration of the significance of the 
etiology of eczema can be adduced than that to be discovered in 
the hands. With these organs man toils to earn his bread, and the 
eczema they display is their protest against the rude contacts which 
are thus necessitated. Unfortunately, in too many patients the 
imperative necessity of bread-winning forbids consent to the best 
methods of relief, viz., temporary disuse of these organs. The feet 
may be similarly attacked, and for similar reasons. All forms of eczema 
are here seen — erythematous, vesicular, papular, pustular, and squamous 
— involving the entire surface, or being limited to the wrists, ankles, 
interdigital spaces, palmar or plantar surfaces, or one or more digits 
of either hand or foot. The motions of the part are so free that fis- 
sures are common and often are exceedingly painful. The itching may 
be severe, and parts of one hand or of one foot may be extensively 
rubbed, torn, or abraded by the other. Vesicles are frequently 
encountered upon delicate portions of the skin, as over the dorsum and 
interdigital spaces, while in the denser palm and sole such lesions are 
deep seated and do not tend to spontaneous rupture, but on puncture a 
clear serous or a cloudy fluid may be evacuated. 

Palmar and Plantar Eczema is commonlv asymmetrical, but 



376 INFLAMMATIONS. 

may be symmetrical. The hands are more often involved than the 
feet. The condition is characterized by the appearance of irregular, 
ill-defined, more or less diffuse areas of dry, dead-whitish, or hypersemic, 
indurated, and thickened integument, which may be fissured or which 
may produce such a tense inelasticity of the surface that the digits are 
semiflexed into the palm or sole. 

Circumscribed patches of eczema, with fairly denned outline, reddish 
in color beneath crust or scale, subacute in course, and accompanied by 
paroxysmal itching, are of common occurrence on the dorsum and also 
on the palm or the sole. In the latter situation they may be traversed 
by one or more painful fissures, the same being true of the fingers and 
the toes. Upon the back of the hand these circumscribed patches are 
prone to pursue an indolent course, improving temporarily under ap- 
propriate treatment and becoming aggravated by every exposure to 
the causes by which they were first induced. 

The long list of etiological factors w r hich may here be efficient can 
scarcely be enumerated. The majority have already been considered 
in discussing the causes of eczema in general. The influence of all 
articles handled in the trades, occupations, and professions, as well 
as the action of toxicants and dyes, must be remembered. Thus, 
printers, bakers, and masons suffer in the hands, and the wearers of 
dyed stockings and coarse, ill-fitting shoes and boots suffer in the feet. 
These so-called "Trade Eczemas" are often due wholly to local 
causes and disappear promptly on removal of the latter. Such con- 
ditions should properly be classed under chronic dermatitis. 

In the matter of diagnosis, it should be remembered that an eczema 
of the hands may follow a dermatitis due to the Rhus toxicodendron. 
In these cases the disease is found usually at the same time upon the 
face and in the genital or mammary regions. Scabies of the hand 
in America is rarer than eczema manuum. In scabies the vesicles 
are firmer, more often unruptured, are fewer, are more isolated, and 
more intermingled with crusts, pustules, and even with bullae, which 
latter are rare in eczema. The discovery of the parasite or its bur- 
rows and a history of contagion will aid in removing doubt. Numer- 
ous pustular lesions in young subjects are, however, according to 
Hebra, most commonly produced by the acarus. The occurrence of 
the eruption on the body elsewhere than on the hand is also to be 
expected in scabies, with respect to which it should be remembered 
that the burrow may not be visible, and that it may be wanting when 
the parasites are present. Psoriasis of the palms and soles is almost 
always accompanied by the presence in other parts of the body of 
patches, the typical characters of which should throw light on the local 
disorder. They are dry, non-discharging lesions, very rarely fissured 
as is eczema of the hands, have a distinct contour (which is rare in 
eczema), and are covered with more abundant and more lustrous scales. 
Eczema is less sharply outlined, and occurs in larger and more diffused 
areas than either psoriasis or syphilis. The scaling syphilodermata 
of the palms and soles occur early and late in the disease, and usually 
after a distinct history of infection. The lesions in syphilis are usually 
isolated, firm, deep infiltrations, circular in outline, with very sharp 



ECZEMA. 377 

definition, and they may be covered with dry, adherent, dirty-white 
scales, beneath which the brown-and-red hue of the persistent lesion 
can be discovered. Superficial or deep circular excavations of tissue, 
single or multiple, with punched or ragged edges, are visible. The 
eruption is rarely, like eczema, accompanied by itching or by dis- 
charge, but painful fissures may form. It occasionally aifects the dor- 
sum of the hand or the foot, favorite sites of eczema manuum, but 
almost invariably it has in such cases swept thither from the palm or 
from the sole. 

In both syphilis and eczema of the hand the right organ in right- 
handed toilers is usually most involved, even where there is apparent 
symmetry of distribution of lesions. 

The treatment demands, first, rest for the organs and a simultaneous 
discontinuance of the exciting cause. In the trades the result of the 
latter can usually be demonstrated by the patient, who notices the dif- 
ference between the condition of the skin on Monday morning after a 
Sunday's rest and that which was distressing on the preceding Saturday 
night. When practicable, protection during labor must be secured by 
the use of gloves, neatly applied finger-cots, rubber-stalls, or bandages, 
retaining a dressing to the part of the hand or the foot that is the seat 
of the disease. For circumscribed, non-discharging patches on the 
dorsum of the hand or the foot the dressing described in connection 
with eczema of the extremities may be applied. When the nature 
of the labor performed is such as to render it impossible to secure 
protection of the hands or fingers in this w 7 ay, something may be 
accomplished in a few cases by directing that the hand be frequently 
dipped in a protective solution or powdered during the hours of labor. 
Thus, printers may dust their fingers with lycopodium, and individuals 
compelled to retain their hands in irritating solutions can anoint these 
organs occasionally with an oily or fatty substance. Generally it may 
be said that an eczema of the hands is too frequently washed, and the 
ill effects of this practice are made evident not only in laundresses, 
but also in mothers who personally attend to the dressing of young 
infants. After each washing, the hands should immediately be cov- 
ered with a suitable dressing, or with a simple lotion, ointment, or 
powder. For mild cases equal parts of tincture of benzoin, glycerin, 
and alcohol diluted more or less with water make a serviceable and 
agreeable application. For protection of the hands and for the reten- 
tion of dressings the cheap white cotton gloves such as are worn by 
infantrymen are convenient and serviceable. They should be large 
enough to go on over the dressings easily and should be washed as 
soon as soiled. When extensively and acutely involved the hand 
should carefully be dressed, each finger being separately wrapped in 
gauze which has been soaked in a lotion or oil or has been spread 
with the selected ointment or paste, and the whole covered with a 
bandage or other dressing. 

The local application must be chosen in accordance with the prin- 
ciples previously given for the treatment of eczema in general. In 
subacute and chronic types tarry compounds are very useful, and caus- 
tics more than ever needful when there are fissures. The fissures may 



378 INFLAMMATIONS. 

often with advantage be painted with compound tincture of benzoin. 
Protective flexile collodion plays an admirable part about the finger- 
nails where irritable seams and fissures form with overhanging fringes 
of torn and ragged epidermis, bordered with red. In painful eczemas 
of this region the immersion, particularly at night, of the entire hand 
or the foot in hot borated water may be practised, followed by careful 
drying and dressing with the selected application. 

When the epidermis of the palm is greatly thickened it should be 
shampooed at night with green soap, pure or in spirit, with the aid of 
hot water, followed by a salicylated soap-plaster or by a salve contain- 
ing white precipitate, 10 to 20 grains to the ounce (0.66-1.33 to 30.), 
or some preparation of tar. For intractable cases caustic potash, in 
the strength of 20 to 30 per cent, solutions, can be mopped well into 
the thickened palm and be followed by a salve application. Van 
Harlingen suggests: 

R 



Hydrarg. ammoniat., 


Bj; 


1 


33 


Adipis, 


3ss; 


2 




Sevi benzoinat., 


Bvij ; 


10 




01. amygd. dulc, 


"lx ; 




66 


Vaselia., 


ad 3vj ; 


ad 24 





M. 

A paste useful in many mild cases and one which dries rapidly is 
made of 10 parts each of glycerin, dextrin, and water. To this may 
be added from 1 to 3 per cent, of thiol or ichthyol. The ingredients 
are mixed on a hot water-bath and form a sort of liniment, which may 
be painted on the skin. Unna's litharge-glycerin-starch paste, described 
on a preceding page, is also a valuable and effective preparation for sub- 
acute cases. For chronic, sluggish eczema of the palms Duhring recom 
mends an ointment composed of equal parts of mercurous nitrate 
plumbic acetate, and zinc oxide ointments. 

For the fingers and hands Unna's mull-plasters, but only if freshly 
imported, fill every requirement. These plasters may be cut int 
strips and be applied with neatness to every digit. Zinc oxide, sali 
cylic acid, tar, and ichthyol mulls are all available for this purpose. 

The condition known as Chapping of the hands and face is, prop 
erly speaking, a dermatitis, since it is usually dependent upon exposure 
to wind and weather and disappears when the cause is removed. It 
sometimes occurs, however, as a condition indistinguishable clinically 
from mild eczema of this region. In those subject to this disorder care 
should be taken through the changeable weather of spring and autumn 
not to expose the skin to cold or wind, especially if the hands have 
been previously immersed in water and are not perfectly dry. In 
many instances the trouble can be prevented by a simple oiling of the 
skin after each washing, or instead of oil equal parts of tincture of 
benzoin, glycerin, and alcohol may be used. This last preparation is not 
only a preventive, but it often affords relief in mild cases. Severer forms 
should be treated as corresponding grades of dermatitis or of eczema. 

Eczema as it Affects the Nails (Eczema Unguium). — There is 
nothing characteristic of eczema in its effects upon the nails. These 
horny plates participate in the diseases which affect their matrices, and 



i— 

■ 



ECZEMA. 379 

thus exhibit nutritional changes. There is, therefore, no eczema of the 
nail proper, but only an eczema of the digit by which the nail is affected. 
In well-marked cases, one, several, or all the nails of either hands or 
feet may lose their polish, or may become rough, punctate, furrowed 
laterally, and clubbed, or may present an appearance suggestive of 
worm-eaten surfaces. They lose their uniformly smooth attachment 
beneath and become tilted on their beds, with marked friability of their 
tissue. An eczematous condition of the skin at the nail-margin may 
be detected, where the usual redness, infiltration, and scaling, with a 
sensation of itching, point to the nature of the trouble. Rarely the nails 
are shed. The most misshapen will be succeeded by smooth and nat- 
ural growths of nail-substance if the disease of the matrix be completely 
relieved. The treatment, therefore, is the treatment of the cutaneous 
disease. Care must be taken to exclude psoriasis (to be generally 
recognized by lesions in other regions of the body), as also ringworm 
and favus of the nails, which end can be reached by microscopically 
examining scales scraped from the nail-surface. 

The finger-tips may be held in hot water for fifteen or twenty min- 
utes at night and the nails then shampooed as vigorously as the condi- 
tion will permit. A soft ointment should then be applied on lint or 
other material. Zinc oxide, white precipitate, salicylic acid, and tar 
salve will be found most effective for the larger number of cases. 
Often the organs may with advantage be protected during the daytime 
by the glycogelatins, powders, gloves, or by rubber-cots. 

Universal Eczema. — In these cases patients should be treated in 
bed. The diet, which is of great importance, should be of unstimulat- 
ing quality ; but it is not to be forgotten that in a disease involving 
the entire surface of the body the strength is sooner or later liable to 
be exhausted, and a supporting dietary, even ferruginous tonics, is often 
required. 

The local treatment is by alkaline and bran-baths, followed by 
lime-water-and-oil lotions, a dusting-powder, ointment, or other dress- 
ing suited to the local condition. In treating universal eczema the 
entire surface does not usually require the same topical agents. Often 
there should be cold-cream salve, freshly made, for the eyelids; a 
dusting-powder for the non -discharging or scaling surface; a salve or 
an oleated lotion for discharging surfaces of the integument; and 
special dressings for the extremities, the ears, the hands, etc. 

Eczema of the Tropics (Prickly Heat). 

(Eczema Solare, Lichen Tropicus, Miliaria Rubra, etc.) 

Under these titles has been described a number of disorders, some 
of which are more closely related to the forms of sudamen considered 
in connection with the functional derangements of the sweat-apparatus, 
others of which are instances of papular eczema, associated or not with 
profuse sweating under the influence of severe physical exertion or of 
high temperatures (solar heat). This disease is aggravated by all exter- 
nal and internal sources of irritation, including indigestion, the use of 









380 INFLAMMATIONS. 

alcoholic beverages, of opiates, of flannel and of chemically dyed gar- 
ments worn next the skin ; undue exertion in a heated medium, fatigue, 
and obesity. 

Etiology. — The disease is more common in those subjected to rapid 
and intense fluctuations in the temperature of the atmosphere than in 
those long accustomed to a relatively hot climate. It is thus exceed- 
ingly common in the northern and central parts of the United States, 
where sudden changes in temperature are frequent and of wide range 
in degree. It attacks alike individuals of both sexes and all ages, being 
often particularly severe in the obese and in infants, whose delicate skins 
no less than their bowels resent sudden and severe thermal changes. It, 
moreover, affects equally the vigorous and the debilitated. It is un- 
questionably seen in the severest grade among fleshy Europeans and in 
Americans emigrating to tropical climates who are habitually ingesting 
alcoholic beverages in excess. 

The disease is characterized by the occurrence of pin-point to pin- 
head-sized vesicles, bright-red papules, vesico-papules, or the two as 
coincident and commingled symptoms. The lesions are exceedingly 
numerous, and may in severe cases cover almost the entire so-called 
" non-hairy " surface of the body, though they are commonly much 
more limited in their diffusion. They are usually acuminate and dis- 
crete, though often thickly set together. They are of rapid occurrence, 
but in consequence of persistence of the cause may be slow to disap- 
pear or may repeatedly recur. The affected region is the seat of charac- 
teristic sensations of tingling, pricking, and burning. The attack may 
last for but a few days or be severe for a week or more. 

Treatment. — The local treatment of prickly heat is, in brief, that 
of the corresponding stage of eczema. Unguents are generally to be 
avoided, as the skin rarely tolerates them, and the same may be said 
of plasters and very cold baths. Baths or lotions (tepid, Avarm, to 
moderately cool, as the feelings of the patient may decide to be most 
grateful), medicated with alkalies, bran, gelatin, or starch, will be found 
useful. After each application the skin is to be dried by gently pressing 
dry towels over the surface, not by rubbing, and is then to be thoroughly 
protected by a free use of one of the dusting-powders, particularly boric 
acid and talc, or one of the zinc stearate preparations. When large 
tracts of the skin are involved, and general baths have been ordered, 
starch in fine powder will often be found well suited for topical em- 
ployment. 

Lotions may also be employed, composed of lead, or of lead and 
opium, or black wash, or alcoholic and ethereal solutions containing 
camphor and glycerin in the proportions given when considering the 
subject of acute eczema. Modifications of oleated lime-water are 






serviceable in severe cases, 


as, 


for 


example : 




R 01. lini, 






f £ij ; 


60 


Paraffin., ) 
Sapon. Castil., J 






aa gij; 


aa 60 


01. bergamii, 






q.s.; 


q.s. 


Aq. calcis, 






ad Oj; 


ad 500 


Sig. For external use. 











M. 



ECZEMA. 381 

This preparation makes a demulcent creamy solution which often 
proves grateful to the skin ; to it may be added zinc oxide or carbolic 
pr dilute hydrocyanic acid, as required. 

The general treatment of the patient is a matter of importance. The 
cause must be removed if possible. Withdrawal from the light, heat, 
and labor of the day, the use of unstimulating food and drink, unirri- 
tating apparel, and rest are of great importance. Saline and acidu- 
lated beverages are usually acceptable to the palate, and useful if not 
drunk too cold. The free use of lemonade, Vichy, Kissengen, Apolli- 
naris, or other pure water, carbonated or aerated, is useful in aiding 
elimination and in supplying the fluids demanded by the cutaneous 
loss through evaporation. 

Prognosis. — The disorder may be trivial or be severe, and may 
last bat for a few hours or for several months. It is usually relieved 
without difficulty, often by domestic measures alone. 



ECZEMA SEBORRH(EICUM. 

(Dermatitis Seborrheica.) 

Duhring was the first observer to show that a type of inflammation 
of the skin, to which he gave the name seborrhoea corporis, was closely 
allied to, and usually consecutive to, seborrhoea capitis. Later, Unna l 
advanced the theory that a single morbid process, to which he gave the 
name eczema seborrhoeicum, is responsible for a number of varied clin- 
ical manifestations which had previously been considered separate dis- 
orders. Under this title he includes seborrhoea sicca (or pityriasis) of 
the scalp, face, and body, some chronic circumscribed forms of eczema, 
and many cases which most observers still believe are forms of psoriasis. 

Though Unna gives to eczema seborrhoeicum a wider range than is 
accepted by the majority of dermatologists, there is little doubt that 
most of the phenomena he describes under this title are intimately 
related etiologically and pathologically. In America Elliott has fur- 
nished an excellent presentation of the subject. 2 In the following 
description the writings of both observers have been freely consulted. 

Symptoms. — Eczema seborrhoeicum almost invariably begins on 
the scalp an,d often remains limited to this region, though frequently 
it extends to the ears, temples, forehead, neck, and adjacent parts. 
The disease is not uncommon on other parts of the body where the 
sebaceous glands are large and abundant, as in the sternal, interscapular, 
inguino-scrotal, axillary, and umbilical regions. It may appear, how- 
ever, on any part of the body and in rare instances is universal. The 
disease is extremely variable in its course and mode of extension. It 
may remain confined to the scalp for years and then extend to adjacent 
surfaces, or appear on portions of the body distant from the scalp, 
leaving the intervening surfaces unaffected. Such spreading of the 
disease may be very rapid, or so slow as to be almost inappreciable, 

1 Monatshft. f. prakt. Derm., 1887 ; and The Histopathology of the Diseases of the 
Skin, 1894. 

2 Morrow's System, vol. iii., p. 273. 



382 INFLAMMATIONS. 

while the lesions may be numerous, extensive, and acute in type, or 
few, scattered, and indolent in character. 

The affection varies considerably in appearance in its different phase 
and especially in different regions. In the scaly form, which is the 
most common, there may be simply a scanty or abundant formation of 
fine branny scales with apparently little other change from the normal 
though the skin may be slightly reddened, and often has the peculiar 
yellowish color which is characteristic of the disease. The scales may 
be large and abundant, and heaped up in dry, adherent masses, simu- 
lating those sometimes seen in psoriasis, but in such cases the scales 
are usually somewhat fatty. Frequently there is a coexisting seborrhoea 
oleosa, with the formation of yellowish to brownish, soft, greasy, and 
non-adherent masses, suggesting crusts rather than scales, under which 
the skin is more or less reddened and the mouths of the follicles 
patulous. 

The disease often appears in the form of oval or rounded macules 
and patches, or as small scale-capped papules which may remain dis- 
crete or may coalesce to form slightly elevated plaques. The macules, 
papules, and plaques are sharply outlined, and patches that are spread- 
ing peripherally frequently present a circinate border with a fading 
yellowish centre. By the coalescence of several such areas poly cyclic, 
gyrate bands may be produced. The color of the lesions is reddish or 
pinkish, modified by the yellow tinge that is nearly always present. 
Scaling and crusting in varying degrees are usually present as in the 
more diffuse forms described above. The lesions may occasionally be 
moist over all or parts of their surfaces, but the characteristic vesicles 
and pustules of eczema are absent and the discharge when present is 
usually distinctly greasy. A transformation to the ordinary forms of 
moist eczema may occur in which the characters, both clinical and his- 
tological, of the original eczema seborrhoeicum are lost. Of the varied 
manifestations of the disease the scaling forms are the most common, 
but in a given case the type may change gradually or rapidly, and 
multiformity of lesions is not unusual. Itching is usually slight and 
mav be absent. 

On the scalp the onset of the disorder is particularly insidious and 
often unnoticed until attention is attracted to it by a thinning of the 
hair, moderate or really annoying pruritus, and a scanty or abundant 
formation of scales over more or less of the scalp. In the early and 
mild forms the condition is practically that described under seborrhoea 
sicca. The vertex is the usual site of the affection, but the entire 
scalp may be involved. The scales may appear in any of the forms 
described above, but are usually fine, dry, grayish, and slightly greasy. 
The lowest layers of the scales are usually firmly attached to the 
underlying surface, which is commonly dry, lustreless, and pale, though 
it may be slightly hypersemic. After the condition has existed for a 
time alopecia is noticed, while the hairs of the affected regions are dry 
and lustreless. The condition may persist for months or years with 
but slight change. In more severe forms the heavier masses of scales 
and crusts described above may form upon distinctly reddened or moist 
patches. Seborrhoea oleosa may complicate the process with its char- 



ECZEMA. 383 

acteristic greasy crusts and oily condition of scalp and hair. In infants 
and occasionally in adults an acute dermatitis may supervene, involving 
portions or all the scalp and usually extending to the adjacent portions 
of the face. The conditions known as Milk-crust (described under 
Seborrhoea) may well be considered a form of dermatitis seborrheica. 
Iu adults circumscribed, oval or circinate, reddened, and scaling, moist 
or crusted patches may appear, chiefly about the temporal and parietal 
regions, often extending to the ears and portions of the face. Occa- 
sionally a sharply defined red band, more or less covered with scales or 
small crusts, may be seen at the margin of the hair, especially on the 
forehead and on the neck. Such bands closely resemble those of psori- 
asis, but usuallv have a more regular and even outline, much less infil- 
tration and thickening of the skin, and lack the characteristic scales 
and outlying separate lesions of psoriasis. 

The ears and the surfaces surrounding them are, after the scalp, 
more frequently involved than other parts of the body. Any of the 
above-described types of the disease may be seen in this region, the 
moist and crusting forms being quite common, especially back of the 
ears, where fissures frequently occur. The disorder not rarely affects 
to a very marked degree the lining of the external conduit of the ear, 
blocking it with crusts and interfering seriously with audition. 

The beard, moustache, eyebrows, and pubes may present symptoms 
differing but slightly from those in the scalp. The disorder may linger 
about the verge of the moustache or other parts of the beard, showing 
its grease and scales even at a distance from the line of hairs, with a 
well-defined reddened surface beneath. The same occurs about the 
line of the eyebrows. Alopecia is uncommon in any of the regions 
except the eyebrows. 

On the face the pityriasic forms are common on the nose and 
adjoining portions of the cheeks, the eyebrows and the region between, 
the eyelids and their margins, and may be exhibited on any part of the 
face. Loss of hair from the eyebrows and eyelids is not unusual (see 
Seborrhoea sicca). The more inflammatory moist and crusting types 
are most frequent along the junction of the alee of the nose with the 
cheeks, but may involve the entire nose and other parts of the face. 
The macular and papular types, above described, are most common on 
the cheeks. 

Seborrhgea Corporis, Seborrhoea Papulosa or Lichenoides 
(Crocker), Lichen Circumscriptum (Willan), Lichen Annulatus 
et Serpiginosus (Wilson), Flannel-rash. — Upon the trunk is 
frequently found Unna's " flower-leaf " or "petaloid" type of the 
eruption which was first described by Duhring and to which have 
been assigned by different authors the titles here enumerated. Its 
favorite sites are the sternum and interscapular region, but rarely it 
spreads in more extensive areas on other parts of the trunk. In a 
well-marked case the lesions appear in the form of sharply outlined 
circles or segments of circles which enlarge centrifu^allv, often coalesc- 
ing to form patches with irregularly circinate outlines. The extreme 
borders, which represent the early stage of the lesions, are made up of 
very small red papules, usually covered with fine whitish or yellowish, 



384 INFLAMMATIONS. 

dry or fatty scales. As the border progresses the centre undergoes 
involution, so that from without inward the patch may display varying 
shades of red, brown, and yellow, while the whole surface is often the 
seat of a furfuraceous desquamation. Round or oval, somewhat ele- 
vated, solid lesions are frequent, and may scale slightly or be covered 
with yellow, greasy crusts. In less perfectly developed cases and in 
those modified with friction of the clothing or frequent bathing there 
may be simply yellowish, finely scaling patches with slightly reddened, 
more or less irregular borders. 

The eruption also occurs upon the trunk and extremities in the form 
of macules, papules, and reddened patches which by coalescence of 
individual lesions may become quite large. These lesions may present 
any degree of scaling or crusting, though there is usually a narrow 
uncovered reddened margin. The affected areas may be dry ■ and in 
form, distribution, and general appearance closely simulate psoriasis; 
or they may be somewhat moist and, as a result of irritation or of 
excessive exudation, may undergo a transformation to a condition indis- 
tinguishable from that of eczema. In most cases the yellowish color 
of the lesions is conspicuous, being most marked when the eruption is 
fading. 

In the axilla and groin the eruption often begins as an erythema 
intertrigo, and owing to the influence of heat, moisture, and friction 
in these regions secreting patches are common. From these points 
the disease often spreads to the adjoining surfaces, the advancing 
margin of the eruption always being sharply outlined and usually of 
circinate contour. 

The dorsal surface of the hands and fingers may be involved, and 
also the palms, on which pea-sized and larger ill-defined scale-covered 
macules are irregularly distributed over the surface. 

Etiology. — In his first description of eczema seborrhceicum Unna 
claimed for it a parasitic origin. He has described three varieties of 
diplococci which he found in the lesions of this disease, beside several 
varieties of bacilli which were occasionally present. Of these he con- 
sidered a mulberry-shaped coccus, which he called the m-orococcus, of 
special importance, and on occasions has produced with it, by the 
inoculation of pure cultures, one or more vesicles, but without repro- 
duction of a patch of true eczema seborrhceicum. He also found 
Melassez's flask-shaped bacillus in the scales. 

Elliott 1 reports on a bacteriological study by W. H. Merrill, of fifty 
cases of eczema seborrhceicum. In all but two cases, on which a solu- 
tion of resorcin had been freely used, bacteria of some kind were found. 
Merrill describes two varieties of diplococci and a bacillus, all three of 
which were present in thirty-one cases, while one or two of them were 
found in most of the remaining cases. Twelve inoculation-experiments 
were made, of which seven were successful; from pure cultures of the 
cocci typical lesions of the disease were produced, from which, in each 
case, the special coccus was recovered and cultivated. One of these 
cocci was decided to. be chromogenic and the cause of the yellowish 

1 "A Preliminary Bacteriological Report on Eczema Seborrhceicum," N. Y. Med. 
Jour., October 26, 1895. 



ECZEMA. 385 

color characteristic of the disease. These experiments, though too few 
in number to be conclusive, would seem, when considered in connection 
with clinical evidence, to leave little doubt of the parasitic origin of the 
disease. The etiological value of the micro-bacillus of Unna and 
Sabouraud is considered in the discussion of seborrhoea. Positive 
evidence of the transmission of the disease from one individual to 
another is difficult to get, though a history of probable contagion is 
sometimes obtained. 

Locally, heat, moisture, friction, and other forms of irritation may 
act as predisposing causes and favor the origin and spread of the dis- 
ease. On the body it is often found in those who perspire freely and 
who wear woollen next the skin. On the scalp it is common in 
those who keep the head covered much of the time. Elliott reports 
that most of his cases occurred in people who lived for the most 
part indoors, and that the affection is unusual on those who live 
largely in the open air. His explanation of the greater prevalence 
of the disease in winter than in summer is that in the former season 
most people live indoors, with poorer ventilation, and bathe less than 
in summer. 

The systemic conditions favoring the development of the disease are 
practically those named as predisposing causes of seborrhoea. 

Pathology. — Even in the mildest grades of the affection, corre- 
sponding to the condition known as pityriasis capitis, Elliott found 
" slight inflammatory infiltration about the papillary vessels and the 
ascending branches from the subpapillary plexus, and along the hair- 
follicles," while in the rete there were some vacuole-like formations 
and a few wandering cells. In severer grades the inflammatory infil- 
tration extended to the subpapillary plexus, and in higher grades to 
the entire cutis, which was then somewhat cedematous. In the rete 
vacuoles were numerous and their origin could be traced to a nuclear 
degeneration. Many wandering cells were present, also karyokinetic 
figures and areas of cell -degeneration. The horny layer was thick- 
ened and easily detached from the interfollicular spaces, but densely 
packed in the dilated openings and necks of the follicles. The seba- 
ceous glands were apparently normal. The coil-glands in many 
instances were dilated and contained cast-off epithelial cells mixed with 
a granular debris, while mitosis and cell-degeneration were frequently 
seen. Elliott found no appearance that would warrant him in believ- 
ing the coil-glands to be the source of the fatty hypersecretion. Unna, 
on the other hand, found fat in the coil-glands, and believes them to 
be the source of most of the fatty secretion characteristic of the dis- 
ease. He also describes an infiltration of small, free globules of fat 
through all parts of the cutis and rete, inside the lymph-sacs. Elliott 
found no evidences of such infiltration ; but Ledermann announces that 
he has recognized it in normal epithelium. 

Unna and Elliott agree in considering all stages of the process an 
inflammation of a catarrhal nature, the immediate cause of which is to 
be found in one or more specific micro-organisms. 

Diagnosis. — From other forms of dermatitis and from simple 
eczema, eczema seborrhoeicum may be distinguished by its origin on 



386 INFLAMMATIONS. 

the scalp, its oily secretion and crusts, the yellowish color and sharp 
outline of its lesions, its tendency to spread peripherally in circinate 
outlines, and by its lack of marked subjective sensations. 

In some forms of the disease the diagnosis from psoriasis is diffi- 
cult, but the location of the lesions on the flexor rather than on the 
extensor surfaces, the oily character of the scales and crusts, the yellow- 
ish color, the greasy and scaly centre of circinate lesions undergoing 
involution, and the general course of the eruption, will usually suffice 
to distinguish the disease. 

Pityriasis rosea may present appearances identical with those of 
eczema seborrhoeicum of the trunk and extremities. The lesions in 
the former disease, however, do not appear on the scalp, usually have 
ill-defined, frayed-out borders, and the enlarging rings present a dry, 
fawn-colored centre which is free from greasy scales. The affection, 
moreover, runs an acute course, rarely lasting more than six or eight 
weeks. 

Treatment. — Sulphur, resorcin, salicylic acid, white precipitate, and 
other preparations of mercury are remedies most useful in the treatment 
of all stages of the disease. For the earlier and dry forms, stronger 
and more stimulating preparations may be used, together with more fre- 
quent washings of the skin, than in the acute, moist forms, which must 
be treated more in accordance with the principles laid down Tor the 
treatment of the corresponding stages of eczema. For the scalp and 
other hairy portions of the body lotions are usually better than oint- 
ments. The lotion recommended by Elliott, containing 3 to 20 per 
cent, of resorcin in equal parts of alcohol and water, is one of the best, 
and should be applied two or three times daily. For the dry forms 
of the disease a small amount of oil — preferably the oil of sweet 
almonds — to prevent the disagreeable drying effect of the lotion 
alone, may be added. Instead of thus combining the oil with the 
liquid, a thin ointment containing resorcin or sulphur may be 
substituted for or applied after the lotion. After soap-and-water 
washings, which should be used often enough to prevent accu- 
mulation of scales and crusts, an oily or fatty application is always 
desirable. 

The most serviceable ointment in the majority of cases is one con- 
taining from 1 scruple to 2 drachms (1.33 to 8.) of sublimated or 
precipitated sulphur, 10 minims (0.66) of balsam of Peru, and 1 ounce 
(30.) of vaselin. Instead of sulphur, resorcin or white precipitate may 
be used. In some chronic cases with much infiltration, sulphur, 
resorcin, and salicylic acid may be with advantage combined in the 
same ointment, while in a few instances the tars, pyrogallol, or chrysaro- 
bin may succeed after the above-named preparations have failed. In 
acute forms, in which the symptoms are more those of an acute 
eczema, pastes and ointments containing salicylic or boric acid are 
valuable until the acute inflammatory condition has subsided, when 
preparations containing sulphur or resorcin should be used. 

The disease is usually more amenable to treatment than eczema, 
though recurrences are common. 



PRURIGO. 387 

DERMATITIS REPENS. 

Under this title Crocker first described an inflammatory disease of 
the skin (usually a consequence of injuries) spreading with a marginate 
border, and, as a rule, beginning over the upper extremities. Cases 
have since been reported by Garden and Nepveu. 1 

The inflammation spreads from a traumatism, eventually producing a 
raw, reddish surface denuded of epidermis and oozing at several points, 
the serous exudate also undermining the apparently sound cuticle. The 
disease spreads with uninterrupted regularity, lasting for months, and 
in cases invading the larger part of an upper extremity. The exten- 
sion is at times from coalescing reddish papules which discharge and 
leave thick, dirty looking crusts. There is a definite margin to the dis- 
eased patch. In cases the disease begins with the formation of blisters. 

The disease has. originated in cicatrices after amputation of a 
finger, from burns, from irritation of the feet after walking barefoot on 
sand, and from splinters under the nail. Crocker believes that the 
dermatitis results from peripheral nerve-irritation, and that there 
is a secondary parasitic involvement of the part. The disease seems 
to be an infectious dermatitis, the traumatism being simply an initial 
factor of the process. The parchment-like epithelium often left after 
healing shows that the process may be one of considerable destruction 
of epidermal and dermal tissues, which may result in diffuse but super- 
ficial atrophy and cicatrization. The diagnosis from eczema depends 
chiefly upon the recognition of the limited outline of the disease, the 
entire denudation of the surface, the undermined edge, and the thinned, 
shining epidermis left after healing. The affection is to be treated as a 
parasitic eczema. 

Two cases of this disease were supposed to have originated in the 
minute traumatisms of the finger-nails occurring when farm-laborers are 
engaged in husking Indian corn by hand ; and one Avell-marked case 
followed the amputation of a finger. An excellent illustration of the 
disease is given in a colored lithograph accompanying the report of a 
case by Stowers. 2 

In three cases treated by us success was obtained in one after employ- 
ing locally a saturated solution of pyoktanin-blue. In another case that 
had resisted continued and varied treatment the lesions disappeared 
rapidly under application of a solution of sodium hyposulphite. Still 
another case yielded to applications of strong white-precipitate oint- 
ment. Crocker recommends a strong solution of potassic perman- 
ganate. 

PRURIGO. 

(Lat. prurire, to itch.) 

(Prurigo Gravis, Prurigo of Hebra, Prurigo Ferox.) 

Prurigo is one of those terms which in the past have led to consid- 
erable confusion in the nomenclature of cutaneous disease. In England, 

1 Brit. Med. Jour., December 11, 1896. 

2 Brit. Jour, of Derm., 1896, vol. viii., No. 1. 



388 INFLAMMATIONS. 

chiefly, it is applied with more or less looseness to disorders accompa- 
nied by the subjective sensation of itching, such as the prurigo mitis 
of Willan, and the disease well recognized under the title " pruritus." 
Prurigo in this loose sense represents a group of disorders due either 
to the invasion of animal or of vegetable parasites, to disorders of 
internal origin, to the ingestion of drugs, or to the other causes de- 
scribed under Pruritus. 

The title " prurigo " in this work is strictly limited to the disease 
to which the name was originally given by Hebra, a disorder beginning 
in earliest life and continuing throughout its duration. Once observed 
only or chiefly in Austria, it has now, in consequence of extensive 
immigration, been occasionally seen in America. 

Symptoms. — Mild and severe forms of the disease are distinguished 
under the terms Prurigo Mitis and Prurigo Ferox, or Agria. 
Incessant care, judicious treatment, climatic influences, and the com- 
forts of life commanded by wealth seem to determine the difference 
between the two. In both varieties of this affection pinhead- to rape- 
seed-sized, Arm, whitish or reddish-white papules form, chiefly and 
primarily upon the extensor faces of the extremities, but from these 
localities gradually extending over the entire surface of the body. 
The itching is of the severest type. 

The earliest symptoms are usually displayed in the latter portion of 
the first year of life, in the form of an urticarial rash, which persists 
and which is finally succeeded by typical papules. These papules are 
minute, often subepidermic, and rapidly become covered with blood- 
stained crusts in consequence of the induced scratching. Then ensues 
a long train of symptoms, including pustulation, fissures, excoriations, 
dense infiltrations, crusts formed of exuded serum and dried blood, 
oedema, diffuse dark-brown pigmentation of the skin-surface in large 
areas, and consequent adenopathy. Fully developed, the disease pre- 
sents in general the same physiognomy in patients of different ages. 
The lower extremities always exhibit the severest manifestations of 
the disease, especially the thigh and leg as distinguished from the 
foot ; though the trunk, the forehead, the cheeks, the neck, the arms, 
and the head may also be involved. Protected surfaces, such as the 
axilla? and the groins, except as regards adenopathy, are free from the 
disease. The general health of the patient manifestly suffers from the 
insomnia and nervous agitation induced by the state of the integument. 
Emaciation, malnutrition, and cachexia are common sequels. The 
mental and moral tone of the patient thus harassed from early child- 
hood throughout an entire life is necessarily profoundly impaired. 
Insanity and suicide are reckoned among its remote consequences. 

The characteristic papules first appear about the eighteenth or nine- 
teenth month of life, the urticarial rash up to the second year produc- 
ing merely whitish plaques upon the skin, commingled with excoria- 
tions and occasionally a marked degree of insomnia. The minute 
papules develop only later on the several regions of preference of the 
disease, at first appreciable only to the touch, later projecting from the 
surface and capped with a blood-scale from the scratching to which 
they have been subjected. Then are to be seen striated excoriations, 



PRURIGO. 389 

bulkier crusts, pustules, dark-brownish-hued pigmentation, and a 
rubbing off of the hairs, such as is often to be seen over the brows 
of male patients with erythematous eczema of the face. (Edema, 
infiltration, and axillary and inguinal adenopathy supervene, so that 
by the end of the second year or at the beginning of the third the pict- 
ure of prurigo is complete. At such an epoch the distinguishing 
marks of the disease are its selection of the extensor faces of the ex- 
tremities and the progression of symptoms with added severity from 
the arms to the legs. The natural furrows of the skin are all exag- 
gerated. In exceptional cases the lesions are seen over the face and 
the dorsum of the feet. Eczematous attacks may complicate any case. 
As a rule, the patient presents practically the same morbid portrait 
after maturity and even in old age as in earlier life. 

Prurigo mitis is the same as the severer form of the disease 
with respect to the evolution of symptoms ; the only difference to 
be observed is in their intensity. The papules are fewer, the recru- 
descence rarer, the itching less intense, and the amenability to treat- 
ment more pronounced. It is to be noted of all cases that they are 
influenced happily by the warm weather of the summer season and 
by special attention to cleanliness and hygiene. 

Etiology. — The disease occurs chiefly in Austria, few cases being 
recorded elsewhere. A patient was exhibited at the International 
Medical Congress in London, whom both Kaposi and Hebra recognized 
as affected with prurigo. Wigglesworth, Campbell, and others have 
reported cases in America. Prurigo is more often encountered in the 
male sex, is never contagious, and is never induced by lice ; but, accord- 
ing to Hebra and Kaposi, it may be grafted upon an hereditary pre- 
disposition. "Scrofula," tuberculosis, malnutrition, "misery," poverty, 
anaemia, and filth are held to be severally favorable to its development. 
The disease is practically limited to the poorer classes living under 
wretched hygienic and social conditions. The superior resources of 
the poorest classes in America will long protect them from the incur- 
sion of this inveterate malady. 

While typical prurigo ferox, as described by the Vienna school of 
authors, is of such rarity that probably less than a dozen cases have 
been reported in America, the opinion is gaining ground that the same 
disease with milder manifestations (prurigo mitis) is much more com- 
mon here than has been believed. Patients with severe prurigo, treated 
by Hebra himself, have found their way to our clinic ; they bore unmis- 
takable symptoms of improvement after a residence in the United States, 
and almost every American expert has observed cases of milder type. 

Pathology. — Kaposi practically admits that, striking as is the clin- 
ical portrait of this disease, its anatomical features are indistinguish- 
able from severe forms of obstinate papular eczema, or from other forms 
of chronic dermatitis accompanied by hyperplasia. The microscope 
reveals proliferation and swelling of rete-cells, cell-infiltration and 
oedema of the papillae, most marked around the vessels, and frequently 
dilated lymph-spaces. There is a scattered deposit of pigment in the 
corium, and many cutaneous muscles (erectores pilorum) are thickened 
and shortened. 



390 INFLAMMATIONS. 

Some authors contend that the papules are solely due to traumatism 
of the pruritic skin. Auspitz believes that the disease is in fact a 
sensori-motor neurosis without essential lesion. Biehl 1 considers it as 
a chronic form of urticaria. Leloir and others find the prurigo-papule 
invariably resulting from a cystic degeneration of rete-cells, thus form- 
ing a cavity which at first contains clear serum with the addition later 
of epithelial debris. The walls of the cyst later undergo keratinization. 

According to Unna, the epithelial changes consist in a circumscribed 
growth of the mouth of the follicle and its periphery, and in areas of 
softening and necrobiosis of the epithelia. Most of the histological 
changes concern the epidermis, but the vessel-sheaths of the cutis 
exhibit a cellular infiltration with dilated lymph-spaces, though the 
blood-vessels are unchanged. The papillary body is oedematous at 
first ; later, flattened as the slow thickening of the prickle-layer pro- 
ceeds. The thickening of the epidermis is most marked in the horny 
layer. 

Diagnosis. — Remembering the extreme rarity of prurigo in America, 
it is to be distinguished chiefly from the various forms of papular 
eczema by the location of its lesions, by the course of the disease, by 
the age of the patient when it is first developed, by the great extent 
of the eruption, and by the uniform type of its lesions. In prurigo, 
also, the fingers and the toes, the flexor aspects of the extremities, and 
the face are more or less spared. Under treatment eczema commonly 
yields at least in some portions of the skin, while prurigo does not. 

From pruritus, prurigo is readily diagnosticated by its general 
physiognomy and history, by its peculiar pigmentations and infiltra- 
tions, and by the special region chiefly affected. But both diseases 
may complicate prurigo, especially eczema, which is then ordinarily of 
artificial origin. In pediculosis corporis the parasites will usually be 
found upon the underclothing, w T hile the lesions induced by the finger- 
nails never form closely packed papules. There is something highly 
characteristic in the widely separated excoriations, the puncta from 
wounds inflicted by parasites, and the inflamed papules seen upon louse- 
bitten patients. 

In scabies the characteristic burrows of the parasites will usually 
be recognized, as also vesicular and pustular lesions. Urticaria can 
be mistaken for prurigo only in the earlier stage of the last-named 
disease. 

Treatment. — In Vienna, sulphur, naphtol, tar, green soap, baths, 
and frequent anointings with oily and fatty substances have occasion- 
ally served to ameliorate the severe symptoms of the disease. Mer- 
cury, ichthyol, salicylic acid, carbolic acid, and boric acid, and diachylon 
and zinc ointments may also be employed upon different portions of 
the skin when indicated. 

The Wilkinson salve, representing a combination of tar, sulphur, 
and green soap, has proved of special value in many cases. Vle- 
minckx's solution (q. v.), followed by hot bathing and corrosive-subli- 
mate baths, 1 drachm (4.) of the sublimate to 30 gallons of w T ater, 
has also been recommended. Internally arsenic has proved valueless, 

1 Arch. f. Derm. u. Pvph , 1884. 



ACNE. 391 

while carbolic acid has occasionally seemed beneficial. Cod-liver oil 
and the ferruginous tonics with the bitters will naturally be indicated 
in many patients suffering from malnutrition. A generous diet and a 
tonic regimen are essential to the management of most cases. 

Prognosis. — The disease usually persists through life. The most 
favorable conditions are those in which the patient is young and sur- 
rounded by circumstances which permit of provision for his needs. The 
disease is probably curable in the early years of life. 

ACNE. 

(Gr. anvrj, a point.) 

(Vaeus. Fr.y Acne ; Ger., Hautfinn t e.) 

Symptoms. — Acne is probably the cutaneous disease of most com- 
mon occurrence, not excepting eczema. The latter affection occurs 
upon the face as often as upon other parts of £he body, yet it is seen 
in persons upon the street with far less frequency than acne. Eczema, 
however, is more distressing in its symptoms, and for that reason 
physicians are more often consulted for its relief, the disease thus 
acquiring a statistical preponderance. Acne is more tolerable, and 
therefore is more tolerated and less treated, especially among the poor. 

The disease chiefly occurs in the second and third decades of life, 
and is characterized in general by the occurrence of several and usu- 
ally numerous, light-red, dull-crimson or violaceous, pinhead- to small- 
nut-sized, ill-defined papules, nodules, tubercles, or non-projecting 
indurations of the skin, often commingled with the symptoms of comedo 
and seborrhcea sicca. The lesions are isolated or irregularly scattered 
over the surface, which, however thickly studded with them, never dis- 
plays a grouping or definite arrangement of the elements of the erup- 
tion. Many of the latter are both slightly painful and tender, though 
upon this point there is a wide range of difference in various indi- 
viduals, some patients tolerating with a surprising equanimity the most 
extensive invasions of the disease. The inflammatory process, which 
manifestly involves the sebaceous glands and periglandular tissues, 
may result in suppuration of several adjacent follicles, as a conse- 
quence of which coalescence occurs and pea- to large-nut-sized cuta- 
neous and subcutaneous abscesses may form. In many cases, however, 
the suppuration is limited to the area of the individual nodule. Every 
feature of the disease, from the smallest papule to the largest subcuta- 
neous abscess, may be displayed at the same moment in an affected in- 
dividual. Under circumstances of special aggravation the disease may 
occur in acute forms, but it is commonly chronic, the acute phases 
being usually accidents of the general process. 

The disease occurs chiefly upon the face, but is seen also upon the 
neck, the back and front of the chest, the genitals, and the extremities, 
the palms and soles alone being excepted. It is emphatically a disease 
of the early puberal epoch in both sexes, though occasionally it is seen 
in middle and later life. In women the symptoms of the disease are 
usually most conspicuous at about the date of menstruation. Acne 



392 INFLAMMATIONS. 

usually lasts for years when unrelieved, during this period being sub- 
ject to occasional exacerbations and remissions, but it commonly spon- 
taneously disappears as full maturity of the body is attained. It may 
persist for years in a mild form with or without the occasional develop- 
ment of the severer grades. In severe cases in which suppuration has 
been extensive it leaves indelible traces of its ravages in the form of 
scars. The various terms used in the description of the forms of the 
disease refer chiefly to its external features. 

Acne is a disorder which frequently is associated with mild or severe 
alopecia furfuracea and seborrhoea capitis, the totality of symptoms 
depending upon similar causes in the susceptible subject. 

Acne Artificialis. — Various substances, either applied topically 
to the skin or ingested, are capable of producing acneiform lesions. 
Among them may be named tar, which may prove an irritant whether 
employed externally or internally, and far more frequently the salts 
of iodine and bromine after ingestion. Tar-acne occurs both among 
workers in tar and in those subjected to the action of this substance for 
the relief of other cutaneous disease. Pinhead- to pea-sized, reddish- 
brown papules then form, at the apex of each of which is perceptible 
a minute blackish punctum, produced by the lodgement of a particle 
of the medicament in the orifice of a sebaceous follicle. Pustular 
and furuncular lesions are, however, also produced, such as occur 
in bromic and iodic acne. In the latter disease Adamkiewicz and 
others have demonstrated the presence of the drug in the contents of 
the pustular lesions. Chrysarobin and a number of other medicinal 
substances are capable of exerting a like effect. 

Acne Atrophica and Acne Hypertrophica are terms employed 
to designate merely the lesion-relics of the disease. In acne atrophica 
there is complete atrophy of the gland-tissue, indicated by a minute 
sunken pit in the site of the former orifice. In acne hypertrophica 
there are, in consequence of the periglandular exudation, a thickening 
of the tissues about the acini, and a projection from the surface in the 
form of persistent, pea-sized, indurated masses. 

Acne Cachecticorum or Scrofulosorum includes the symp- 
toms encountered in the subjects of struma, scorbutus, marasmus, 
chloro-ansemia, and tuberculosis. The lesions are more often developed 
on the trunk and the extremities than over the face, and are papulo- 
pustules, pinhead- to bean-sized, particularly indolent, and remarkable 
for their livid, purplish, lurid-red, or violaceous tint. The lesions are 
rarely indurated ; more often they are seen as softish, pus- and blood- 
containing nodules, sluggish of career, and leaving minute cicatrices. 
Their features are due entirely to the general cachectic condition of the 
subjects in whom they occur. Colcott Fox describes acne scrofuloso- 
rum as it occurs in infants. 1 

Acne Indurata. — This type of the disease is less frequently ob- 
served than several of the other forms, but it is one which possesses 
distinct clinical features. Induration of the base of the acne-papule 
may be noted in many cases of the simple form of the malady, but 
in others the glands seem generally to be distinguished as minute, 

1 Brit. Jour, of Derm., November, 1895. 



ACNE. 393 

very firm nodules, with no tendency to suppuration. The surface of 
the skin is often without marked change in color or heat, the indi- 
vidual lesions exhibiting at times an unnaturally whitish aspect. They 
are felt when the finger is passed over the surface as dense, often 
conical projections, occasionally painful, and giving to the touch a 
sensation suggestive of the surface of a nutmeg-grater. Comedones 
may often be discovered intermingled with the papules. The disease 
when well marked is likely to be extensive, occurring with charac- 
teristic expression among brunette, hairy male patients well advanced 
to the twenty-fifth year. It is often generalized over the forehead, 
cheeks, and chin, and the back of the neck. 

Acne Papulosa. — In acne papulosa the lesions are of a papular 
type, ranging in size from that of a millet-seed to that of a coffee- 
bean, whitish or reddish in color, and varying in the amount of indura- 
tion at the base. They are evidently due to infiltration of the peri- 
glandular tissue, and are often commingled with pustules, papulo-pus- 
tules, and comedones. At the apex of each papule is often distinguished 
the blackish point characteristic of acne punctata, or a minute, greasy, 
yellowish- white spot, which represents the non-pigmented extremity of 
an inspissated sebaceous plug. 

Acne Punctata. — In this variety of acne the apex of the papule 
exhibits the characteristic blackish pun ct urn of the comedo about which 
the papule has formed. 

Acne Pustulosa. — This form is probably the most frequently 
observed of all the expressions of the disease. The lesions are apt to 
be commingled with papules, comedones, and intermediate phases 
between the functional and inflammatory disorders of the glands. The 
pustules almost invariably originate in previously formed papules and 
may be large or be small, containing merely a droplet of pure pus, or, 
when a true furunculosis ensues, a teaspoonful or more of pus may be 
mingled with blood and serum. This accumulation may be evacuated 
surgically or accidentally, or be absorbed, or may remain for a long 
period of time in a species of cyst, whence it can finally be expressed. 
In aggravated cases two or more of these pustulo-furuncular depots 
may coalesce, forming nut-sized abscesses, or, not rarely, may become 
united by fistulous tracts, through which there is free communication 
of the fluid contents of two or more chambers. 

Acne Vulgaris is a term applied by several authors to the com- 
posite eruption which is common to many clinical cases. Here the 
various lesions described above (papules, pustules, comedones, etc.) 
are associated, usually on the face and over the shoulders, each in sev- 
eral degrees of development, often in conjunction with the scars left 
by a prior eruption. 

Acne Disseminata is a name given by some authors to acne vul- 
garis, the common inflammatory type of the disease above described. 

Acne Kebatosa is the Acn6 cornSe of French authors. In this 
affection cornified masses of sebum distend and project from the orifices 
of the sebaceous glands, particularly over the neck, but also over the 
face, the trunk, the elbows, the knees, and other portions of the body. 
There is some doubt whether this disease should not be classed with 



394 INFLAMMATIONS. 

ichthyosis, which it unquestionably resembles, or with keratosis pilaris. 
By some French authors the condition is considered an early stage of 
keratosis (psorospermosis) follicularis. 

Under this title Crocker l reports four cases in women in whom there 
appeared on the face, chiefly about the angles of the mouth , firm, painful 
inflammatory papules, succeeded by pustules and crusts. From the cen- 
tre of these lesions could be expressed short, soft or horny plugs which 
were formed evidently in the sebaceous glands or hair-follicles. On 
removing the plug the lesions healed slowly, in many instances leaving 
a scar. The disease was persistent, lasting in one case for forty years. 

Keloid-acne (Dermatitis Papillaris Capillitii) is a name 
which has been given to an inflammatory folliculitis and perifolliculitis, 
leaving deep hypertrophic scars, usually, in the thick epidermis over 
the neck and the back of the trunk, though seen also upon the scalp 
and face. Wisps of thick, distorted, and evidently altered hairs pro- 
ject here and there from the affected surface. Reddish, and even vas- 
cularized nodes, tubercles, and bridges occur at irregular intervals, in- 
terspersed with occasional acne-pustules and deep-seated, broad, even 
gigantic comedones. Sclerotic tissue, in brief, forms about the site of 
the acne-process quite like cicatricial keloid of the trunk and other 
situations. 

Acne Parasitica is a term which eventually will be extended to 
include many of the varieties of the disease described above. Some 
of the pustular lesions of acne result solely from dissemination of pus- 
cocci over the face by the finger-nails or other means. The good re- 
sults obtained by an appropriate therapy are often the fruit of a de- 
struction of these micro-organisms. 

That some of these lesions are at times infected with the bacillus 
tuberculosis there can be no question. Not only have tubercle-bacilli 
been recognized in the pustules of some forms of acne, but singular de- 
generative and even ulcerative results have in rare cases been produced, 
not solely due to the ordinary processes distinguishable in acne. 

Acne Urticata is described by Lowenbach 2 as occurring on the 
scalp, face, and other portions of the body. The primary lesion, which 
is preceded by itching and burning, is a small wheal which enlarges to 
the size of from 6 to 12 mm. The centre then becomes paler and de- 
pressed and shows a vesicle which dries into a crust. The crust falls, 
leaving a small scar which in time becomes depressed and shining 
white. The full development of a wheal requires from four to six 
days. The later stages of the process suggest acne necrotica both 
clinically and histologically. 

Ulerythema Acneiforme is probably due in part to the toxins of 
a tubercular infection, and is assigned in this work to another chapter. 

Contagious Acne (Diekerhoff and GraAvitz) of horses (horse-pox) 
is compared by Kaposi to contagious impetigo rather than to human 
acne. It is characterized by an eruption of flattish, pea-sized and 
larger bullae, seated on an inflammatory base, and visible over the 
region of the mane, the back, and the shoulders. 

1 Brit. Jour, of Derm., 1899, p. 1. 

2 Arch. f. Derm. n. Syph., 1899, vol. xlix., p. 29. 



PLATE VI 




Aene-keloid of the Back. 






ACNE. 395 



Etiology. — The causes of acne are numerous and in many cases 
obscure. It is common to describe the puberal change in both sexes 
as a frequent cause of the disease, but a physiological crisis is rarely a 
disease-factor unless the full and normal development of the period 
be prevented by accident, disease, or malnutrition, or by excessive 
demands upon the vital forces in other directions. With the growth 
of the hair in both sexes at the period of puberty there is an unusual 
activity of the sebaceous glands, and this physiological is then the 
more readily perverted to a pathological activity. Thousands, how- 
ever, escape acne who survive puberty. The disease, none the less, 
is prone to appear first at this time of life, and, if not improperly 
treated, to disappear spontaneously when full maturity of the body is 
attained. There is a close physiological connection between the genital 
function and organs, and the appendages of the skin, not only in man 
but also in the lower animals (antlers of the stag, plumage of birds, 
etc.), and the disturbances of the former may be reflected to the latter. 
The effect of castration upon the male of many animals is displayed in 
the appendages of the skin. In the same way perverted sexual 
instincts and habits, or a poorly regulated sexual hygiene and uterine 
disease, are frequently associated with an acne. The most common 
causes of acne are associated with disturbances of the gastro-intestinal 
tract, including constipation, dyspepsia, and malnutrition from various 
causes. Acne cachecticorum, struma, tuberculosis, and the cachexias, 
and the medicinal agents capable of producing artificial acne, either by 
ingestion or after external application, have already been accused. 

It should not be concluded, however, that any one of these condi- 
tions can be recognized as efficient in the majority of patients. Many 
cases of acne occur in healthy young people of both sexes. A careful 
record of many cases of the disease will exhibit in other organs no ail- 
ment common to the larger number of patients. The causes of the 
disease may be local, such as suffice merely to induce primarily altera- 
tion in the consistency, quantity, or chemical character of the sebaceous 
secretion, and, either as a cause or result of this alteration, there ensues 
an adenitis or a periadenitis and subsequently an infection with micro- 



organisms. 



The use of cosmetics, the neglect of soap, or the use of the cheaper 
and irritating varieties, excessive shaving on the part of the young 
man, friction from hatbands, " frizzes," " bangs," and dyed veils, too 
frequent fingering of the face, improper compression of the neck by 
tight collars, and a long list of other agencies may prove the immediate 
or the remote cause of the disease. It is believed that blondes are the 
more frequent sufferers ; but this observation may have been suggested 
by the circumstance that in those of light complexion the symptoms of 
the disease are more conspicuous and disfiguring. It certainly seems 
that young brunettes, with thick skins and abundant growth of dark 
lauugo-hair, furnish the most obstinate cases. 

The cause of acne is the mechanical irritation produced by the 
comedo-plug which is formed by inspissation of the contents of the 
gland and by hyperkeratosis of the neck of the follicle. An efficient 
cause in some cases is perversion of the glandular function or excretion 



396 INFLAMMATIONS. 






by the gland of toxic substances, in consequence of which the secretion 
is changed in character and becomes a chemical irritant to the tissues. 
Infection with pus-cocci or possibly with other micro-organisms is an 
important factor in many cases. The micro-bacillus of Unna and 
Sabouraud is found constantly in the lesions of acne, as it is in those 
of comedo and alopecia areata. It is believed by many that this 
bacillus is the sole direct cause of comedo and acne. 

Pathology. — The earliest stage of the acne-papule is that described 
under comedo. Hyperplasia of the horny layer at the follicle-neck 
may continue without decided inflammatory changes and produce the 
small, firm, normal-colored papules of this type of acne indurata, or 
complete occlusion of the duct of the gland may result in a simple 
retention-cyst. 

As a rule, however, the presence of the comedo-plug excites an 
inflammation which may be limited to the common excretory duct and 
the sebaceous gland, but which involves often the hair-follicles and 
usually the tissues surrounding these structures. The pathological 
changes depend upon the extent and intensity of the process. In gen- 
eral, however, the inflammatory changes are of one or the other of 
two types. In the first type the inflammation is subacute and per- 
sistent, resulting in a denser infiltration of the tissues and producing 
the indolent, indurated papules often seen in old and stubborn acne. 
The process may result in hyperplasia of the connective tissue, as in 
acne hypertrophica. In the second type of inflammation the process 
is more acute and is followed by suppuration, which may be limited to 
the sebaceous gland, and produce neither scarring nor loss of the hair, 
or may include the follicle and surrounding tissues, causing destruction 
of the hair-papilla and the production of a permanent scar. When 
several glands and the intervening tissues are involved in this sup- 
purative inflammation small abscesses are formed, considerable tissue 
is destroyed, and the resulting scars are large and disfiguring. 

According to Kaposi, there is no question that the first stage of the 
disease is always an anomalous performance of secretion or excretion in 
the sebaceous gland. Unna takes an opposite view, citing two main 
features: first, a parakeratosis resulting in occlusion of the follicular 
orifices, and, second, the presence in the crypt-contents of a bacillus 
which he believes is pathognomonic for this disease. 

Diagnosis. — The typical facies of acne vulgaris is readily recog- 
nized by the characteristic features already described. The reddish 
papules, pustules, comedones, and "lumps" in the skin of the face of 
a young subject; the evident involvement of the sebaceous glands; the 
history of a chronic affection destitute of itching and, though possibly 
picked, quite unscratched ; the occasional blood-crusts where lesions 
have been squeezed or incised, are all significant facts. The pustular 
syphilide of the face is not only to be differentiated by its share in the 
history of an infectious disease, but also by the occurrence of charac- 
teristic crusts, its selection by preference of the regions about the nose 
and mouth, its evolution in groups, and its sequels in the form of super- 
ficial or deep ulcerations. Nevertheless, simple acne is common in 
syphilitic subjects. Potassium iodide is so frequently administered 



ACNE. 397 

for the relief of syphilis, and in so large a majority of cases induces 
its artificial acne, that the latter eruption often precedes the evolution 
of the macular syphilide, and also with frequency masks the latter by 
a commingling of lesions. Simple acne is common also among those 
who are veterans of syphilis. Acne certainly at times resembles variola, 
and cases of the former have been mistaken for variola. In most 
instances the absence of fever and a brief delay will end any doubt. 

Treatment. — Acne is an" entirely remediable disease in every case 
properly managed. Scars of ancient ravages of the affection are, it is 
true, indelible, but even these are smoothed down in the progress of 
time so that they become yearly less conspicuous and disfiguring. 

The general treatment of acne requires a careful and exhaustive 
study of the special requirements of each individual case. For most 
patients the question of diet is of the highest moment — that appro- 
priate for the school-boy and the school-girl, or the adolescent 
employed in factory or on the farm or in domestic labor. All well-fed 
subjects of acne are benefited in a high degree by reducing the quan- 
tity of food ingested, especially in the item of meats. A milk-diet, 
or one composed largely of fish, fruits, and the lighter vegetables, 
will usually brighten up the most obstinate case. Confectionery, 
highly spiced food, pastry, hot bread and cakes, sugars, and fried 
articles are all excluded with great advantage. In most cases much 
will be accomplished by cutting down the quantity while regulating the 
quality of the food eaten. Alcohol is generally to be prohibited ; and 
it is idle to treat a severe case of acne in a young male subject who 
cannot for the time abandon the use of tobacco in every form. 

An important consideration, at the outset of treatment of a patient 
affected with acne, relates to any local or internal medication previ- 
ously employed. A large proportion of all patients first claim the 
attention of the physician after ingesting drugs or making topical 
applications which have decidedly aggravated the original trouble. 
With or without the advice of others, such patients have often been 
engaged for months in swallowing potassium iodide, " red clover," 
and various nostrums calculated to " drive out " the disease ; or in 
rubbing over the skin equally noxious proprietary substances. In 
every such instance the skilled physician should delay active treatment 
of the affection until the artificial acne has subsided, and the real con- 
dition of affairs can clearly be recognized. The patient should be 
directed to discontinue his or her former practice, to bathe the affected 
part with hot water at night, and after the surface is dried to apply any 
bland unguent. By these simple measures alone many cases can be 
improved greatly, and some be relieved completely. 

The constitutional treatment of acne rests for its success upon the 
discovery of the cause of the disease. Many patients certainly require 
no internal medication, being entirely relieved by local treatment. A 
thorough investigation of the habits of living — food, diet, bathing, 
occupation — and bodily functions, according to the methods described 
in the chapter devoted to General Diagnosis, is essential at the outset. 

Since dyspepsia and constipation are frequent causes of the disease, 
it is necessary to correct these disorders when present. A blue pill or 



Sy; 




60 




f3ij; 




8 




33; 




4 




gr. v; 






33 


f 3j ; 




4 




ad f 3viij ; 


ad 


240 


M. 



398 INFLAMMATIONS. 

calomel on several consecutive nights followed by a saline laxative in 
the morning is usually indicated at the outset of treatment. The 
cascara compounds are especially valuable when it is necessary to con- 
tinue the use of a laxative for more than a few days. Some modifica- 
tion of Starting acid mixture, such as the following, will be found 
suitable for other cases : 

R Magnes. sulphat., 

Acid, sulphur, dil., 

Sodii chlorid., 

Ferri sulph., 

Cardamom, tinct. co., 

Aq. dest., 
Filtra. 
Sig. A tablespoonful in a tumblerful of water before breakfast. 

Other cathartics, saline and alterative, will often prove service- 
able. The mineral waters, Hathorn, Carlsbad, Hunyadi Janos, Racoczy 
or Kissingen, a tumblerful before breakfast, are exceedingly valuable 
in cases of habitual intestinal torpor. When there is an acid form of 
dyspepsia the rhubarb and soda mixture, or potassium acetate in -J 
drachm (2.) doses, will be serviceable. Mercurous iodide in small doses 
three times a day is often of value in aiding elimination. Some cases 
improve rapidly on taking each night enough castor-oil to cause a daily 
free evacuation of the bowels. Salol and other intestinal antiseptics are 
effective in some cases. 

In many cases of acne due to inactivity of the large intestine 
thorough irrigations of the bowel, together with daily exercises which 
will strengthen the abdominal muscles and stimulate peristalsis, are 
followed by complete recovery. Large quantities of pure water drunk 
between meals and before meals aid greatly in the matter of elimina- 
tion. As a rule, it is advisable to take little or no liquid — especially 
if iced — with food, or for an hour after eating. The unwholesome habit 
of rapidly bolting food without proper mastication is thus largely over- 
come. In many instances, however, a cup of w^arrn, but not strong, 
tea, cocoa, or coffee at the close of the meal is an aid to digestion. 

Daily exercise in the open air is necessary to stimulate sluggish 
glandular systems into proper functional activity. Such exercise to be 
of value should be carefully adjusted, both in kind and in amount, to 
the needs of the individual. 

A most important part of the treatment in every case is without 
question the daily bathing of the entire surface of the body (with 
exception of the face, which requires special attention as elsewhere 
shown ; and excluding the menstrual period in women) with water 
as cool as can be tolerated, by rapid sponging, followed by brisk 
friction with coarse towels or with a flesh-brush until the skin is 
glowing. Common salt may be added to this bath in the strength of 
\ pound of salt to each gallon of water. The results of this treatment 
are excellent in the majority of cases, especially in those in which the 
patient has been accustomed to the hot or Turkish bath, which may 
aggravate affections of this class. 



ACNE. 399 

In nervous and overworked patients sufficient sleep at regular hours 
should be secured, and when possible short periods of rest during the 
day should be obtained. In some of these cases the indigestion and 
consequently the acne can be made to disappear with no other treat- 
ment than ten minutes of complete physical and mental relaxation 
before meals, and half an hour of comparative inactivity after eating. 
In a growing boy or girl relief of acne often can be best accomplished 
by shortening the school-hours, and by carefully selecting studies and 
occupation adapted to the physical and intellectual development of the 
individual. 

The sexual life of both the married and the unmarried should be 
regulated according to the laws of hygiene. Uterine disease, when 
this complication exists, should receive proper treatment ; and this, far 
less by topical applications than by attention to the general health, as 
patients of this class are often chlorotic young women with menstrual 
derangements, leading sedentary lives, or overworked at the school-desk, 
the sewing-machine, or the shop-counter. 

With the recognition of the several causes of acne, general and 
local, internal medication for the relief of the disorder should be 
directed wholly to the general condition of the patient. Calcium sul- 
phide, long highly esteemed in the management of acne, is set down 
to-day as " side by side with the ludicrous specimens of therapeutic 
empiricism. " Arsenic, however, is highly recommended in acne papu- 
losa by Duhring and Taylor. The internal employment of ergot 
in full doses for the relief of acne has occasionally been followed by 
excellent results. Cod-liver oil, iron, strychnine, phosphorus, the 
mineral acids, and the bitters are needed in chlorosis and cachexia. 
Glycerin in teaspoonful to tablespoonftil doses three times daily has 
proved valuable (Gubler). Pepsin, pancreatin, and other aids to diges- 
tion are often of temporary value. 

In all cases, whether previously treated or not, which have been 
purged of suspicion of an artificial element, the local treatment is of 
prime importance, and in the perfection with which its details are 
observed lies the key to success. It is not the selection of one of the 
several remedies of the manv advocated for the relief of the disease, nor 
yet the successive substitution of one for another to meet any transitory 
indication in each case, that conduces to the happiest result ; but it is 
rather the use of a single method of recognized value, and its skilful 
adaptation to the changing conditions of the disease. 

An effective method of local treatment is found in curetting the 
lesions as practised by Fox, of New York. A ring-curette is drawn 
over the affected surface so as to express the contents of the lesions and 
to stimulate others to activity. The subsequent bleeding is encouraged 
by sponging with hot water. All comedones are expressed, and the 
subsequent treatment is that suggested below. 

It is always necessary to evacuate the contents of pustules, to express 
from the summits of papules (where are the orifices of sebaceous ducts) 
all densely inspissated plugs of sebum, and to remove any comedones 
present with the aid of the comedo-extractor. In many cases this oper- 
ative treatment, especially the removal of comedones, is easier and more 



400 INFLAMMATIONS. 

satisfactory after several days of the hot bathing and ointment-applica- 
tions recommended in the following paragraphs. For the purpose of 
opening the superficial and smaller purulent collections the long needles 
used by gynaecologists are decidedly preferable to a knife, and for the 
larger and deeper furuncular lesions a bistoury with a delicate and very 
narrow blade should be used. A slight degree of skill will here repay 
the operator. Piffard's acne-lance is useful in this connection, as 
also is Volkmann's spoon (modified by Auspitz), which may be em- 
ployed in removing pathological debris. By counter-depression with 
the fingers the whitish-yellow or blackish orifice of the duct may be 
detected, and at this point the needle or the bistoury should be thrust 
sufficiently deep to insure removal of pent-up pathological accretions. 
Should blood flow in droplets from any of these slight wounds, 
it is rather to be encouraged than repressed, as relieving the hyper- 
emia and engorgement of the small periglandular phlegmon. In one 
or several sittings all lesions requiring such interference should care- 
fully be attacked, and immediately after each operation, preferably 
while pus and blood still are oozing, the part is to be bathed for sev- 
eral minutes with water as hot as can be borne with comfort. For 
many reasons the hour before retiring is preferable, though not always 
practicable, in treating such cases, as then a bland ointment can thor- 
oughly be applied and be permitted to remain until the following 
morning. 

When one or several of these operations have largely relieved the 
skin of its engorgement and retained inflammatory products a systematic 
use, at night, of the spiritus saponis alkalinus or tincture of green soap 
(q. v.) with hot water, should for a time be practised. Many cases, 
which do not require the minor surgical operation described above, 
should from the first be treated in the following manner. As the face 
is the commonest seat of the disease, for the purpose of description, 
it may be considered as the affected part : 

The patient is seated before a basin of water, which is as hot as can 
be tolerated with comfort, and, with a pad of white flannel or a soft 
sponge, the face is bathed until the skin is thoroughly moistened and 
softened by the heated water and steam. From ten minutes to half an 
hour may well be employed in this way, it being a fertile source of the 
improvement which follows. While the face is still wet all pustules 
which have formed are emptied, and a sufficient quantity of spirit of 
green soap is poured over the flannel or the sponge, with which the face 
is then thoroughly scrubbed. Finally, the skin-surface is cleansed with 
a surplus of the water, is carefully dried, and is anointed with a sulphur 
ointment. 

Some range may be observed in the employment of the two sub- 
stances named. Thus, the spirit may be diluted with cologne- or rose- 
water, one-half or more ; or the soaps employed, in less imperative 
cases, may be the best toilet-soap, Sarg's glycerin or sulphur soap. 
The ointment, too, may be compounded by adding from 15 grains 
to 2 drachms (1.-8.) of sublimed sulphur and half of the same quantity 
of resorcin to the ounce (30.) of lanolin, cold-cream salve, or vaselin. 
In the morning the face is to be washed with cold water. 



ACNE. 



401 



This operation of steaming, soaping, and anointing is to be contin- 
ued, according to the severity of the case and the tolerance of the 
patient, nightly, or twice a day, or on alternate nights, until the face 
is free from papules and other inflammatory lesions. After from two 
to ten days of this vigorous treatment the face is usually unsightly, 
reddened, slightly tumid, and often moderately furfuraeeous. To the 
patient the skin feels tense, slightly painful, and as if made of leather. 
When this artificial dermatitis is severe the hot water and ointment 
may be employed for a few occasions without using soap. For sensi- 
tive skins it may be necessary to employ for a few days some of the 
sedative lotions and ointments recommended for the treatment of acute 
eczema. When the artificial dermatitis has subsided the shampoo may 
be resumed. With the removal of the lesions the spirit, or other prep- 
aration of soap, may for a time be discontinued. The improvement 
which follows is marked and speedy, and usually is satisfactory to the 
patient. When this condition is reached a wider latitude of treatment 
is permitted. Gradually the hot ablutions may be withdrawn, and the 
use of less stimulating lotions and ointments may be advised. Sulphur, 
having the highest reputation in the disorders of the sebaceous glands, 
is a constituent of many of the lotions thus employed. One of the best 
is Vlerninckx's solution (see page 93), of which from 10 to 60 drops in a 
tablespoonful of water may simply be mopped on the face and allowed to 
remain over night, or may be applied with gentle friction and massage. 

Taylor l advises the following : 



R 



Sig. 



Sulphuris loti, 


3iij ; 




12 




Camphorse spts., 


t* 3iij ; 




12 




Sodse biborat., 


3ij ; 




8 




Glycerin., 


f3yj; 




24 




Aq. fontan., 


ad f ^iv ; 




ad 120 


M. 


Shake well and 


apply freely, leaving a 


thin 


film of powder over 


face. 











Various combinations of sulphur with alcohol will be found useful. 
Thus, Kaposi recommends a paste composed of: 



Sulphur, prsecip., 


3ijss ; 


10 


Spts. vin. rect., 


f ajss ; 


45 


Lavand. spts., 


f Sijss ; 


10 


Glycerin., 


ttlxx; 


1 



33 M. 



Sig. To be spread over the face and retained during the night. 



Or, 



R Sulphur, nor., 

Spts. sapon. virid., 
Lavand. tr., 
Peruv. bals., 
Camphor, spts., 
Bergamot. ol., 



Sijss ; 
f3v; 

f^ij; 

T»lxx; 
fflxv; 



10 

20 

60 

1 

1 



Sig. To be applied over the face at night 
1 American Clinical Lectures, Xew York, 1878, vol. iii., No. 10 



33 

33 M. 



2(5 



i 



402 INFLAMMATIONS. 

Duhring recommends the following : 



R Sulphur, prsecip., 




3ij; 


8 


Glycerin., 




f SPij ; 


_ 8 


Alcoholis, 




f Jj; 


30 


Aq. calcis, 




fgj; 


30 


Aq. ros., 




f?ij; 


60 


Sig. Shake the vial before 


using. 







M. 



Resorcin, next to sulphur, is probably the most valuable remedy in 
acne as in other sebaceous gland disorders. It may be used in the 
above formulae in place of sulphur, or combined with it in strength 
varying from 2 to 10 per cent. Ichthyol and thiol are similar in their 
action to sulphur, and sometimes succeed when the latter fails. They 
may be used in ointments, in lotions, or combined with glycerin. The 
discoloration produced is easily removed, as both substances are soluble 
in water. 

Ammoniated mercury, 2 to 15 per cent., in lanolin or other 
simple ointment is an effective remedy. Mercuric chloride is very 
•generally employed in the strength of from -J- to -|- grain (0.008-0.033) 
to the ounce (30.) of emulsion of bitter almonds as a lotion ; and the 
protiodide and biniodide of the metal are similarly applied in lotions 
and unguents, in the strength of from 5 to 10 grains (0.33-0.66) 
to the ounce (30.). One should be careful not to make use of mercu- 
rials at the same time with a compound of sulphur, lest a chemical 
combination occur by reason of which mercurous sulphide (sethiops 
mineral) be precipitated upon the skin and produce the appearance of 
comedo. 

For mild cases an excellent lotion is obtained by adding 2 drachms 
each (8.) of simple tincture of benzoin and glycerin to 4 ounces (120.) 
of distilled water, to which, where a more stimulating effect is desired, 
1 ounce (30.) of cologne-water or of alcohol may be added, or 1 scruple 
(1.33) of sulphurated potassa. 

Occasionally rumex ointment may be used with advantage as the 
basis of sulphur and other salves in acne. It is prepared according to 
the following formula : 

R Rum. crisp, rad., 

Adipis, 

Cerse flav., 

Aq. pur., 
Wash and bruise the roots ; boil for two hours ; strain ; evaporate to 4 
ounces (120.) ; gradually add the wax and lard in a melted state; and 
stir until cool. 

The English sulphur hypochloride, in ointments of the strength of 
those given above, and sulphurated potassa, ^ to 1 scruple (0.66-1.33) 
to the ounce (30.) of lotion or of ointment, are effective, but objection- 
able on account of their odor. 

Mercurial plaster may be applied on strips of linen or iodated gly- 
cerin (5 parts of eaoh of pure iodine and potassium iodide to 10 of 
glycerin) may be applied with a brush twice daily until from six to 
twelve applications have been made. Van Harlingen employs 1 



Six; 


270 


Syj; 


180 


3j; 


30 


q. s. 


q. s. 



ACNE. 403 

drachm each (4.) of sulphurated potassa and zinc sulphate to 4 ounces 
(120.) of rose-water. Fox applies \ drachm (2.) of chrysarobin to the 
ounce (30.) of collodion. Taylor advises from 5 to 25 grains (0.33- 
1.6) of zinc iodide to the ounce (30.) of vaselin. 

The paste recommended by Lassar is useful in some cases — that is, 
1 part of beta-naphtol, 2^- parts each of vaselin and sapo viridis, and 5 
parts of precipitated sulphur — spread over the skin for from fifteen to 
twenty minutes, and then wiped off, when the surface is dusted with 
French chalk. In obstinate cases with few lesions the touching of the 
parts Avith pure carbolic acid or with salicylic acid, or with acid nitrate 
of mercury, is useful, but such measures should be condemned for the 
majority of patients at or near puberty. A fine needle connected with 
the negative pole of a galvanic battery may be employed to destroy 
single and indurated papules or papulo-pustules. 

For chronic and indolent cases one of us devised a modification of 
the local treatment of acne by the aid of an instrument called the 
" massering-ball," figured on page 104. This instrument consists of a 
stout, short handle of hard rubber, connected by means of a slender steel 
neck with a ball set in a steel socket, the small sphere rotating within 
the cup of the socket, as in an ordinary ball-and-socket joint. The free 
play of the ball is aided by its bearing upon a smaller ball set in the 
neck of the cup attached to the handle, which is fixed upon the socket 
at an angle sufficiently convenient for the operator, whose eye can thus 
better follow the play of the ball. The ball is constructed of hard rubber, 
and the area of its impact upon the skin at any moment is about that 
of the human thumb of average size similarly placed. When actually 
in use the ball travels with ease as well along the angles of the nares 
with the cheeks, the bridge and root of the nose, and the regions below 
the symphysis menti, as over the brow, the temples, the chin, and the 
cheeks. When necessary to cleanse the instrument the ball is detached 
by unscrewing ; but the entire instrument may be boiled without 
impairment of its usefulness. 

When ready for treatment the skin is first operated upon with 
aseptic needle ana 1 comedo-extractor until all pustules and subepidermic 
foci are emptied and conspicuous comedones are removed. After this 
the surface is rendered aseptic, either with one of the bichloride lotions 
or with a solution of formalin (40 per cent, of formic aldehyd) in the 
strength of from 0.5 to 2 per cent., according to the sensitiveness of 
the patient's face. The massering-ball is then rotated freely over the 
surface, and deep pressure is made upon the affected region, with the 
result of bringing into view groups of previously inconspicuous come- 
dones, which are in turn removed by the extractor or "presser." 
Lastly, massage of the surface is practised with the ball by the aid 
of a salicylated cocoanut-oil or by one of the sulphur unguents. 

The use of caustics in acne, though recommended, should in general 
be discountenanced as needless. In extreme induration of the lesions 
these may be rubbed with fine pumice-stone until the desired effect is 
produced. 

The powders employed in the milder forms of the affection are finely 
powdered sulphur, which may freely be dusted over the face, and those 



404 INFLAMMATIONS. 

compounded in various proportions of starch, rice-flour, zinc oxide, and 
bismuth subcarbonate. 

Relief of acne in young male patients has been reported after the 
passage of the urethral sound, and in both sexes by hot- and cold- 
water injections of the vagina and urethra. 

Prognosis. — The majority of patients, even when untreated, even- 
tually recover. This natural involution of the disease is commonly 
attained in proportion as the body arrives at the maturity of its devel- 
opment and accomplishes the sum of its important functions. Appro- 
priate treatment has, however, a satisfactory influence in hastening the 
recovery of a large number of all patients. A small minority suffer 
from the unsightly complications and sequels of the malady (cicatrices, 
keloid). Exceedingly rebellious and even grave cases occur in the 
cachectic, those long and improperly treated, and those who from 
necessity are continuously exposed to influences unfavorable to the 
involution of the disorder, such as the subjects of epilepsy habitually 
ingesting potassium bromide, and the victims of syphilis requiring 
persistent use of the salts of iodine. 

ACNE ROSACEA. 

(Rosacea, Gtttta Rosea, Telangiectasis Faciei, N^vus Araneus, 
"Brandy-nose," Copper-nose. Fr., Acne Rosee, Coupe- 
rose J Ger., KUPFERROSE, KUPFERFINNE.) 

Acne rosacea is most often displayed upon the nose, cheeks, and 
chin, but may occur on any part of the face, and rarely on the lateral 
regions of the neck. It is seen usually in middle life, and occurs rarely 
before the twenty-fifth year. 

Symptoms. — In the first grade there is a more or less diffuse 
pinkish or dusky, but transitory redness, involving the extremity of 
the nose and its contiguous parts, which coloration may extend from 
this region in a somewhat symmetrical figure over the cheeks and chin. 
The redness may be uniformly spread over the regions involved, or 
displayed in irregular, ill-defined blotches which vary greatly in size 
and shape. The spots may be roundish, radiating, stellate, linear, 
tortuous, or of fantastic outline. The colors vary from a delicate rosy- 
pink to a deep-purplish crimson. Minute capillaries often ramify over 
the erythematous surface. The effect is a marked unsightliness, for 
which chiefly, or only, the advice of the physician is sought, as the 
affected parts give rise to little or no subjective sensations. Under 
pressure with the finger the color disappears, the surface seems cool 
rather than hot, and the sebaceous glands are seen to be affected, as 
there is usually present either a seborrhoea oleosa or an accumulation of 
yellowish-white, moderately inspissated sebum in the patulous orifices 
of the gland-ducts. 

The disorder varies greatly with the general condition of the patient. 
At times it may scarcely be perceptible ; again, after the stimulation 
produced by ingested' food or by alcohol, after mental excitement, a 
paroxysm of coughing or laughing, or exposure to external irritation 
the lesions may be even conspicuously deforming. This condition may 



ACNE. 405 

endure for months or for years and then disappear, or may be succeeded 
by the second stage of the malady. 

In a second grade of the disease the redness becomes permanent, 
though subject to frequent variations in intensity, capillaries dilate 
passively and appear as conspicuous, tortuous, straight, or anastomosing 
lines of reddish color about the nose, cheeks, chin, or forehead. Firm, 
purplish-red, painless, pinhead- to pea-sized nodules or papules often 
rise from the erythematous surface, and they either display minute 
superficial and tortuous blood-vessels in the integument with which they 
are covered, or they project from a base about which such a telangiec- 
tasis has very irregularly been developed. The lesions are apt to be 
intermingled with those of seborrhoea oleosa or with acne vulgaris. 
When fully developed, this stage of the disease, though generally not 
productive of marked subjective sensation, produces an exceedingly 
conspicuous deformity. 

In the third stage (which is the most pronounced of the three) 
roundish, sessile or pedunculated, lobulated or pendulous, firm, elastic, 
pinkish-red, bluish, livid, or violaceous vegetations, traversed by a finer 
or larger network of blood-vessels, slowly develop about the affected 
part of the face, chiefly the nose. These vegetations may be single or 
multiple, and in the latter case may be isolated or so closely united as 
to be scarcely distinguishable from one another. The acneiform lesions 
seen in the second grade of the disease may here also be apparent. 
The nose is often cold to the touch when bright red in hue, and it may 
be peculiarly oily or greasy in appearance in consequence of a seborrhoea 
oleosa of the part. The so-called " brandy-drinkers', " "wine-drink- 
ers'/' and "whiskey-drinkers' " noses are of this class. In some cases 
there is a uniform and symmetrical hypertrophy of all the soft parts 
of the nose, which may thus attain colossal proportions. It is these 
extreme consequences of acne rosacea to which the term Rhixophyma 
has been applied. 

The course of the disease is very slow, and in by far the largest 
number of patients does not produce the exaggerated types of the 
second and third grades. The lesions may persist indefinitely as indo- 
lent symptoms of the malady in any one of its stages, or in a case in 
which there has been no new growth of vessels or of tubercles may 
proceed to spontaneous involution. 

Etiology. — The first and second grades of acne rosacea are common 
in women either at puberty or near the period of the menopause, in 
those who are pregnant, or in those who suffer from utero-ovarian 
disease, frequent miscarriages, sterility, irregular performance of the 
menstrual function, or chlorosis. 

The disease, however, is seen in men of early and of late adult life. 
In both sexes it may occur in anaemic and asthenic states ; in both, also, 
its association with gastro-intestinal dyspepsia, constipation, and the 
immoderate use of strong tea and alcoholic drinks — beer, wine, and 
spirits — is a matter of common observation. According to Kaposi, 
the rosaceous nose of the wine-drinker is bright red; that of the beer- 
drinker, cyanotic or violet ; that of the spirit-drinker, smooth, supple, 
fatty, and dark blue. The new growth of vessels and tubercles, with 



406 INFLA MM A TIONS. 

the rhinophyma of the advanced grade of the disease, is much com- 
moner in men than in women. In those whose faces are bronzed by 
exposure to the weather the telangiectasic condition of the cheeks, 
rather than of the nose, is of frequent occurrence. Veteran sailors and 
soldiers are thus commonly affected. Persons who have frozen the 
nose or the cheeks on one or more occasions are similarly liable to 
telangiectases. Any externally or internally operating cause which 
tends to retard the capillary circulation in the superficial portion of 
the skin is capable of inducing this result. Acne rosacea is at times 
conspicuously displayed in the mulatto. 

Pathology. — In the first stage of acne rosacea there is merely pas- 
sive hyperemia. The circulation in the superficial capillary plexus is 
retarded. Persistence of this condition for long periods of time results 
in paresis of the capillaries, with their consequent dilatation and hyper- 
trophy, phenomena which characterize the second stage, the sebaceous 
gland-disorder being a complication of the process. In the third stage 
the nodules are composed of newly formed gelatinous elements, which 
later are replaced by organized connective tissue. According to Biesia- 
decki, there are also dilatation and hypertrophy of the sebaceous glands, 
with dilatation, hypertrophy, and new growth of the superficial blood- 
vessels, and enlargement also of those trunks which ascend from the 
corium. There is no marked epithelial hypertrophy (Unna). 

The disease, however, is viewed differently by authors. By some its 
obvious connection with acne vulgaris is denied ; by others it is 
regarded as a seborrheal eczema. According to Besnier and Doyon, 
this disease represents : (a) superficial or deep, at first intermittent, 
then persistent, hypersemia ; (6) sebaceous hyperemia (acne-eczema), in 
which there are unquestioned steatorrhea and implication of the seba- 
ceous glands with infiltration and possibly exfoliation of the skin ; (c) 
deep hypersemia with infiltration of the corium and plastic products 
about vessels, follicles, and perifollicular tissue ; (d) telangiectases, as 
described above ; and (e) hypertrophies of the perifollicular derma. 

Diagnosis. — Acne vulgaris is distinguished from acne rosacea by the 
absence of telangiectasis, and of the hypertrophic growths which char- 
acterize the developed lesions of acne rosacea. The tubercular syphilo- 
derm is recognizable by its tendency to ulceration and crusting and 
by the entire absence of telangiectasis. When the tubercles of syph- 
ilis are limited to the extremity of the nose (they are usually small in 
consequence of the influence of treatment) they often degenerate into 
characteristic, split-pea-sized, irregularly circular ulcerations, which 
are superficial in seat and frequently isolated. They leave similarly 
shaped and sized depressed cicatrices at the tip and neighboring parts 
of the nose. As the process is much more rapid than in acne rosacea, 
these lesions, considered in connection with the absence of telangiec- 
tasis, furnish the most significant diagnostic symptoms of the disorder, 
for they often occur late in the history of syphilis, in individuals in 
middle life, and in varying shades of a dull-reddish color, circum- 
stances particularly favorable for confusion regarding the identity of 
the two diseases. 

Zoster from involvement of the superior maxillary branch of the 



ACNE. 407 

trigeminus, with diffused redness of one side of the nose and efflores- 
cence of vesicles over its tip and ala, strongly resembles acne rosacea 
with pustular lesions ; but in zoster the painful character of the dis- 
order, its limitation to one side of the face, its transitory career, and 
its vesicular lesions are characteristic. 

Lupus vulgaris, like syphilis, when occurring upon the nose, is to 
be recognized by the tendency of its papulo-tubercular lesions to ulcer- 
ation and crusting, by the absence of vascularity, and by the frequent 
presence of characteristic cicatrices. Unlike syphilis and acne rosacea, 
however, the history of lupus vulgaris usually extends from early 
childhood. Lupus erythematosus is characterized by a definite outline, 
by a superficial infiltration and elevation of the border of the patch, by 
an atrophic or scarred centre, by adherent scales, and by its symmetri- 
cal diffusion over much larger and defined areas, commonly extending 
from the bridge of the nose well on to the cheeks. 

Treatment. — So far as there can be said to be any internal treat- 
ment of acne rosacea, it is that employed in acne vulgaris ; but in 
neither disease can such treatment be confidently described as effective 
in the dispersion of the local lesions. The treatment is that of the 
patient rather than of his disease. When alcohol has been in any 
degree productive of the local effects the use of spirits, wines, and beer 
is to be interdicted ; but as regards confirmed rosacea this prohibition 
will prove to be of little avail. The disease when resulting from 
spirit-drinking may persist after years of total abstinence. 

The diet should be of the character proper for the patient with 
acne. All imbibition of hot liquids, even tea and coffee in excess, 
should be restricted as tending to congest the blood-vessels of the face. 
Everything having the same result in the habits, the occupation, or the 
clothing of the patient should be, as far as possible, deprived of 
influence, as, for example, wearing of tight collars and corsets, working 
over hot fires, etc. 

In many patients who are the subjects of rosacea, as distinguished 
from the younger class of sufferers from acne vulgaris, there are evi- 
dences of lithaBmia, gout, and similar conditions, requiring even stringent 
rules in many particulars for the conduct of life. The use of sugar 
in many of these cases is to be restricted, meat should be forbidden or 
permitted but once in the day, and other articles of food be selected 
with special care. Tobacco should never be allowed to male patients 
with well-marked symptoms, and the daily general bath described in 
the preceding chapter as of importance in the treatment of acne should 
here also be prescribed. 

All gastrointestinal sources of mischief should also be set aside 
when practicable. In acne rosacea, even more than in acne simplex, 
dyspepsia and constipation are conspicuously effective factors. 

Internally, nux vomica, ergot and ergotin, ichthyol (ammonio-sul- 
phate), mineral acids and alkalies, and arsenic have been recom- 
mended. Most of these drugs are valueless in removing the symptoms 
of the disease unless their use is indicated by the general condition of 
the patient. In gouty patients blue pill and alkalies, though not of 
themselves capable of relieving the rosacea, may serve to aid the 



408 INFLAMMATIONS. 

patient ; the same may be said of the use of iron in chloro-ansemic 
women. 

The local treatment of the first grade of acne rosacea is substantially 
that of acne vulgaris. Stimulating lotions of green soap, formalin, 
alcohol, mercuric chloride, or sulphur in connection with ablutions 
in hot water, are of the highest value. In addition, the various oint- 
ments containing sulphur, resorcin, mercuric oxide, and iodides, and 
the continuous application of mercurial plaster should be employed if 
necessary. 

Van Harlingen reports rapid results from the application, several 
times in the day, of a lotion composed as follows : 



R Sulphuris prsecipit., 3j > 4 

Pulv. camphorse, gr. v; 

Pulv. tragacanth., gr. x ; 

Aq. calcis, ] -- c<z- --on 

a n r aa i ^i ; aa o0 

Aq. rosas, { OJ ' 



33 



M. 



Fox, of New York, applies chrysarobin in traumaticin, \ drachm 
(2.) to the ounce (30.) ; but this drug should be reserved for intractable 
cases, as it may produce severe dermatitis. After the production of 
these effects, however, the benefits secured may be appreciable for 
months. 

In the second stage of the disease the treatment is the same as in 
the first stage, but when all the inflammatory phenomena have yielded 
and the causes of the local congestion have been removed, the vessels 
and remaining nodules may be destroyed by single or by multiple 
puncture of each with a fine cambric needle attached to the negative 
pole of a galvanic battery with six to ten elements in the circuit. This 
operation is better than the knife, and it may be regarded to-day as 
the effective method of removing blemishes produced by dilated blood- 
vessels in this stage of rosacea. The method is simple, readily exe- 
cuted, requires no anaesthetic, and is in many ways superior to other 
methods, to which resort should be had when electrolysis cannot be 
employed. Some vessels may completely be destroyed with the pro- 
duction of so slight a cutaneous cicatrix that in the course of a few 
months it cannot be recognized by the unaided eye. 

For details of this simple operation the reader is referred to the 
chapter on Hypertrichosis. For the cambric needle may often be 
substituted with advantage a fine jeweler's brooch, annealed in the 
flame of a spirit-lamp. The vessels may be entered in one or several 
places, and the operation be repeated until the last thread-like evidence 
of their existence has disappeared. The number of cells brought into 
the circuit must be somewhat graduated to the requirements of each 
case and to the locality of the skin operated upon. Fewer cells can 
be tolerated for the lip and alse nasi than for the root of the nose, the 
cheeks, or the forehead. Next in value after this operation may be 
named : 

Brushing the part 'cautiously with solutions of caustic potash, from 
10 to 30 grains (0.66 — 2.) to the ounce (30.) of water; and the local 
use of pure carbolic, chromic, pyrogallic, and glacial acetic acids, 



ACNE VARIOLIFORMIS. 409 

acetum cantharidis (Taylor), sulphur iodide, or solution of mercury 
pernitrate. Before these drugs are employed, however, an effort should 
be made to produce exfoliation by spreading over the part a plaster 
made of green soap. Unna's mercurial plaster-mull is similarly 
applied. Kaposi highly recommends the solution of iodated glycerin 
employed by him in acne vulgaris (q. v.), which solution is painted 
over the part from eight to twelve times daily for three or four suc- 
cessive days, and is immediately covered with gutta-percha tissue. 

Multiple scarification of all new-growths after the manner of attack- 
ing lupus-nodules, erasion with a dermal curette or with a Braun spoon, 
and surgical ablation or decortication of tumors by ligature and knife, 
are also available. After any destructive attack upon the diseased por- 
tions of the skin soothing lotions, fomentations, or ointments should 
regularly be applied. 

Prognosis. — A favorable prognosis can be given in cases in which 
the disease occurs in its milder forms. Even in cases complicated by 
marked telangiectasis and hypertrophy the results of treatment are often 
in the highest degree encouraging. Notwithstanding the most ener- 
getic procedures, however, the vis-a-tergo of passive hyperemia, involving 
often the deeper and unassailed blood-vessels, may work its slow pro- 
gress. For women the future is in general more promising than that 
of men. With the most unfavorable prognosis, however, it is to be 
remembered that, after all, the disease is one of deformity rather than 
of physical discomfort. 



ACNE VARIOLIFORMIS. 

(Acne Frontalis, Acne Rodens, Acne Necrotica, Acne Atro- 
phica, Folliculitis Varioliformis. Ft., Miliaire Scrof- 

ULEUSE.) 

This disease is not to be confounded with that to which Bazin and 
other French writers once gave the name Acne variolifo?"me, viz., mol- 
luscum epitheliale (molluscum verrucosum of Kaposi). 

Symptoms. — The disease is characterized by the occurrence over 
the centre or the upper portion of the forehead, the temples, or margin 
and central portions of the scalp, of pea- to bean-sized, firm, reddish- 
brown papules, which become pustular at the apex, and which are 
commonly exceedingly indolent and often grouped. The pus of these 
lesions desiccates in crusts which are flattish, closely adherent, and 
i apparently depressed below the general level of the skin. On the fall 
J of the crusts there is left a rather deeply tinted brownish-red cicatri- 
: form lesion, somewhat resembling the cicatrix of variola, from which 
the disease received its name. The scar much more closely resembles, 
however, the results of the involution of the pustulo-tubercular syphi- 
loderm in groups. The subjective sensations are slight, at times there 
is itching. The disease tends to recur and is exceedingly chronic in 
course. 

In exceptional cases the disorder occurs in other regions than those 
named above ; for example, over the dorsal and sternal aspects of the 



410 INFLAMMATIONS. 

trunk, about the nose, and within and about the concha of the ear. 
In one of the authors' patients (the subject of the accompanying illus- 
tration) the disease left very disfiguring scars on the right ala of the 
nose. The lesions are often traversed by a hairy filament. In some 
cases the affected regions are so thickly invaded that the resulting scars 
produce a cribriform aspect in the integument. Occasionally the ar- 
rangement of the lesions is linear or is circinate. 




Acne necrotica. 



The variations displayed are exceptional, but worthy of note. Severe 
confluent, serpiginous, and very extensive developments of the malady 
may be seen. According to Boeck, the hue of the papulo-pustule is 
due to minute capillary hemorrhages, which later become invisible in 
consequence of tumefaction of the overlying integument. 

Etiology. — The sexes are represented nearly equally among the 
subjects of the disease, who are, as a rule, in or near middle life. The 
causes of the disease are unknown, but the microbic origin of acne 
varioliformis, together with necrotic granuloma and folliclis, is well- 
nigh established. 

Pathology. — Fordyce and Sabouraud state that the disease begins 
in the upper part of the hair-follicle, from which point it extends to the 
entire follicle and to the sebaceous gland. Various micro-organisms 
are found in the lesions, but the active agent is apparently a staphylo- 
coccus. Sabouraud l believes the disease is always preceded by sebor- 
rhoea. The inflammation usually terminates in central necrosis and 
subsequent scar-formation. 

According to Unna, acne varioliformis is produced by a mixed 
infection. At first there is plugging of the lanugo-follicles with a firm 

1 Annal. de Derm, et de Syph., 1899, p. 845. 



IMPETIGO HERPETIFORMIS. 411 

scale. Along with this is a marked perifollicular cell-agglomeration, 
penetrated by extensively dilated lymph-spaces. Later the follicle dis- 
tends with an abundant growth of a bacillus 1 to 1.25 fi in dimensions. 
Still later the diplococci of seborrheic eczema are seen with colonies of 
bacilli in the centre of the distended sac. At first the diplococci simply 
furnish a sero-fibrinous crust. By their active development at a later 
stage in the depth of the tissue they lead to necrosis and subsequent 
cicatrization. Some of these cases may be due to infection with the 
toxins of tubercle-bacilli. Acne varioliformis occurs in typical develop- 
ment upon the faces of the tuberculous. For further details in this 
connection, the paragraphs devoted to the paratuberculoses of the skin 
(Necrotic granuloma, folliclis, etc.) should be consulted. 

Diagnosis. — The lesions are to be distinguished from the syphilo- 
derm named above, from acne vulgaris, and from variola. The points 
of distinction are : the absence of fever, present and precedent ; the 
absence of other symptoms of syphilis ; the localization of the eruption ; 
and the absence of intermingled comedones and other symptoms of 
acne disseminata. The involvement of the scalp-surface is not alone 
sufficient to distinguish it, as syphilodermata and occasionally come- 
dones are visible in the scalp above the brow. 

Treatment. — The disease usually yields readily after the use of 
antiseptic lotions or of ointments containing white precipitate, resorcin, 
sulphur, mercuric chloride, formalin, or boric acid, though lesions are 
likely to develop after suspension of treatment. In severe cases caustics 
or galvano-puncture may be required. 

IMPETIGO HERPETIFORMIS. 

Knowledge of this rare disease is limited to the reports of thirteen 
cases observed by Hebra and Kaposi in the Vienna clinic; one by 
Heitzmann in New York ; one by Pataky ; and a few scattered cases 
reported by others. Of the Vienna patients, twelve were women, and 
the most of these were in the puerperal state. 

Symptoms. — Pinhead-sized pustules, usually closely packed in 
groups, filled with an opaque or a yellowish-green fluid, are discovered 
upon the surface of the groins, the navel, the axillae, the breasts, and 
other portions of the body. A dirty brownish-colored crust is formed 
by rupture or desiccation of these lesions, and about this crust, single, 
double, or triple concentric circlets of new and similar lesions appear in 
succession, each series undergoing a similar process of involution. The 
eruption thus extends until the circlets from different foci of origin 
unite, and extensive areas of the skin are involved. Beneath the 
crusts the skin is reddened, infiltrated, smooth, and covered with a 
new epidermis, moist as in eczema or exhibiting a denuded corium. 
It is never in a state of ulceration. In the course of three or four 
months the eruption is well-nigh universal, the skin being swollen, 
shining, and crust-covered, or seamed with excoriations surrounded 
by circles of pustules. Exceptionally there are multiformity of lesions 
and the occurrence of the disease in women who are not pregnant. 
The lingual mucous membrane exhibits grayish, centrally depressed 



412 INFLAMMATIONS. 

patches, well defined in contour. Alternate rigors and febrile accesses 
mark the periods of recrudescence when new pustules form. Delivery 
seems to have no favorable effect upon the course of the disease 
in pregnant women. An endometritis with peritonitis was discovered 
post mortem in a single case. Two women only of the thirteen 
Vienna patients survived ; one suffered from a relapse after several 
weeks of improvement. 

The Etiology and Pathology of the disease are necessarily obscure, 
having in view the relatively small number of reported cases. 

Dumesnil, Marx, and Dubreuilh have examined the skin removed 
from living subjects of the disease, and have discovered dilatation of the 
blood- and lymph-vessels with swollen endothelium and embryonic 
cells surrounding these, especially in the papillary body at the base of 
the pustules. Cocci were present in the pustules, which are always 
within the epidermis, and there was acanthosis of the palisade-layer of 
prickle-cells. Post-mortem evidences of nephritis, endometritis, and 
pulmonary tuberculosis have been recognized in different cases. 

The Diagnosis of the disease is between herpes, dermatitis herpeti- 
formis, and pemphigus. 

In herpes the purely vesicular character of the lesions and the cycli- 
cal career of the disease indicate its nature. In dermatitis herpetiformis 
there is commonly a distinct multiformity of lesions, and the subjects 
of the disorder are not, in such great preponderance, pregnant women. 
In pemphigus the size of the bulbe and their distribution in other than 
concentric groups will indicate the character of the disease. Special 
care should be taken to distinguish impetigo herpetiformis from pem- 
phigus vegetans. The locality primarily invaded is the same in both 
diseases. For details consult the paragraphs devoted to the malady 
last named. 

The Treatment is conducted on general principles, including the 
administration of antipyretics, and the local employment of alkaline or 
of carbolated baths ; starch and other dusting-powders ; anodyne, carbo- 
lated, or simple salves ; and coal-tar. The uterus should be relieved 
of its contents. 

The Prognosis is necessarily grave. 

PEMPHIGUS. 

(Gr. TTEfi^i^ a bladder. ) 

(Pompholyx. Ger., Blasenausschlag.) 

With respect to the question whether pemphigus should be regarded 
as the name of a distinct disease or of a group of several diseases, various 
opinions are held. At one time every dermatosis displaying blebs was 
accounted a form of pemphigus. With increasing knowledge there 
has been a greater reluctance to distinguish any disease by this specific 
term alone merely because of the presence of a bullous exanthem, and 
as a result a number of affections exhibiting bullous efflorescence upon 
the cutaneous surface have been wholly disassociated from both pemphi- 
gus and what the French term the " pemphigoid eruptions." For some 



PEMPHIGUS. 413 

authors there is only a chronic pemphigus ; for others, in order to 
establish a diagnosis of pemphigus, the existing lesions should repose 
directly upon the skin without exhibiting a peripheral inflammatory 
areola, or at least be the expression of a disease with periodic exacerba- 
tions in a determined career. 

In many morbid conditions of the skin bullae are present, when it is 
manifestly improper to call the disease pemphigus. For example, these 
lesions are exhibited typically in some forms of lepra, in inherited 
syphilis, often as a result of the traumatisms of insects, and of several 
infective processes. To assert that a disease is a pemphigus in one of 
its varieties, it is necessary to recognize the presence of other symptoms 
than bullae. 

Symptoms. — The distinctions respecting the bullous dermatoses 
established by Brocq are worthy of recognition. In a first class are 
included, as suggested above, the bullae which are epiphenomena of some 
malady (e. g., erysipelas). In a second class the bullae are either the 
main feature or one of the main features of a disease. The second 
class includes both the dermatoses in which the eruptive symptoms 
are not commonly of bullous type, but which become such under 
special conditions (e. g., polymorphous erythema bullosum), and those 
eruptions to which the term pemphigus is assigned by the best 
authors. 

It is to this second class, and to the last-named subdivision of the 
class, that the title is assigned in the paragraphs which follow. In this 
group are included : (a) Acute pemphigus ; (b) Chronic pemphigus ; (c) 
Pemphigus foliaceus ; (d) Pemphigus of the newborn ; (e) Pemphigus 
of young girls ; (/) Pemphigus vegetans of Neumann. 

It should be understood at the outset that these are simply clinical 
distinctions of value for the time being. There are doubtless other 
forms of pemphigus, some of which are named below ; and there are 
unquestionably morbid conditions here described which may be classed 
later more appropriately with other affections. 

Acute Pemphigus. — The rarity of this disorder has led observers to 
deny its existence. It is seen, however, though very rarely, in typical 
expression chiefly in infants and in young adults. 

Pemphigus Acutus Benignus Febkilis occurs in adults, in chil- 
dren, and in infants, but more frequently among the very young. It 
may be epidemic in hospitals and in other public institutions. With or 
without an antecedent febrile movement, the blebs may appear before 
or within a fortnight after birth in infants that are well nourished or 
cachectic, more often the latter. In favorable cases the evolution of 
the disease is completed within three or four weeks. Any part of the 
body may be affected ; but, what is important from a diagnostic point 
of view, the face, the hands, and the feet are often exempt. The con- 
junctivae and mucous lining of the mouth may, however, become 
implicated. In some cases the pemphigus may be of hemorrhagic type. 
Underneath the lesions a reddish, glistening rete is exposed. The ter- 
mination may be fatal. The greatest care is required to differentiate 
the disorder from syphilis, which is commonly not a difficult matter 
since the eruptive symptoms in syphilis are first developed, as a rule, 



414 INFLAMMATIONS. 

at a later period, are less acute, and they invariably exist upon the 
person of an infant exhibiting the characteristic cachexia of lues. 

Pemphigus Acutus Malignus Febrilis is still rarer. As in the 
case of infants, in adults there may be marked febrile antecedents and 
systemic disturbance. The eruption of pea- to large nut-sized bulla? 
may be sparse or be abundant, covering in some cases the entire body 
and attacking mucous surfaces. The vesicles or bulla? may be tense, 
flaccid, and tilled with clear, serous, or puriform contents. Covering 
the floor of the lesion may be seen a smooth, raw, mucous layer or a 
diphtheritic exudation. The bullae, as a rule, are large, well formed, 
and irregularly distributed over the body, the face, and the limbs, with 
acuity of development. After a few hours or a few days crusts form, 
the latter, after their fall, leaving a slightly pigmented surface. The 
malignancy of this affection is at times formidable, death occurring in a 
week after the onset of the malady. In these cases there is usually a 
decided febrile movement, with vomiting, headache and other pains, 
stupor, delirium, and great nervous anxiety. In some cases the exan- 
them is productive of intensely pruritic or burning sensations ; and 
when generalized the difficulty of placing the patient in a position of 
ease greatly aggravates the nervous state. 

Pathologically the lesions are elevations of the horny layer with 
serum, having an cedematous prickle-layer in the periphery, with a base 
represented by an involuted prickle-layer permeated with leucocytes. 
Diplococci and saprophytes are found in numbers at the base of each 
bleb. According to Weyl, Bulkley's Herpes gestationis is an example 
of Acute pemphigus adultorum. 

Chronic Pemphigus (Pemphigus Vulgaris). — The term Pemphigus 
Vulgaris is applied to the more common clinical forms of the malady, 
and it has been employed generically by many authors to include all 
varieties of the disease. The title Pemphigus Diutinus has been 
used also to designate that pemphigoid eruption in which the character- 
istic lesions follow each other with rapidity and in profusion, fresh 
bulla? appearing each day. Fortunately, all forms of the disease are 
relatively rare. 

The cutaneous lesions in chronic pemphigus are usually preceded by 
febrile symptoms ; and the disturbance of the economy is declared in 
cardiac, respiratory, and gastro-intestinal derangements of function. 
The fever may be continuous, remittent, or intermittent, and is usually 
aggravated just before the appearance of a fresh crop of blebs. 

The face, the trunk, and the extremities are chiefly involved. The 
eruption first appears bilaterally, somewhat symmetrically or asym- 
metrically, in reddish macules of rather vivid hue, in the centre of 
each of which appears later a whitish elevation of the epidermis sug- 
gesting a wheal. Either upon these or upon unaffected points of the 
skin there subsequently form tense, well-rounded or oval vesicles 
developing into bulla? varying in size from that of a pea to that of a 
hen's egg and even larger, and in number from three to six only, to 
a hundred and more ;• they are usually irregularly distributed (Pem- 
phigus Disseminatus), but they may be clustered in groups, or very 
rarely be found the younger encircling the older lesions, so as to form 



PEMPHIGUS. 415 

a circinate patch (Pemphigus Circinatus) ; their contents are serous 
or bloody (Pemphigus H^emorrhagicus), or, later, purulent, the 
color corresponding with that of pus. The bullae often coalesce, and, 
whether ruptured or not, the involution of the lesion is accomplished 
by desiccation and crusting, the crusts being usually found to contain 
blood, pus, epithelial debris, and the exudate from the base of the bleb. 
Beneath such a crust there forms a new epidermis, which is usually 
violet, purplish, or bluish red in color, and which later displays a 
brownish pigmentation which may survive the disease for several weeks. 
Occasionally the affection occurs with very mild and even insignifi- 
cant phenomena (Pemphigus Bejstgnus). There may be no fever, 
and very few blebs appear ; in some cases but a single lesion can be 
seen (Pemphigus Solitarius). In other instances the fever is 
intense ; the eruption abundant ; the skin ©edematous, painful, pru- 
ritic, excoriated ; and the underlying lymphatic glands are enlarged. 
This general condition with exacerbations and remissions may persist 
for months, and the eruption may then disappear never to return, or to 
recur, as it often does, in the future. 

Clinically, many of the distinctions between the varieties of pem- 
phigus disappear. Between the benign processes just considered and 
the grave form of pemphigus foliaceus described below several inter- 
mediate gradations can be observed, and even the most benign may at 
times unexpectedly assume the most malignant phases. Pemphigus 
Malignus is a name given generally to those intermediate varieties of 
the disease, most of which are distinguished by persistent and pros- 
trating fevers ; by cachexia, especially in infants ; by the occurrence 
of diphtheritic patches upon or about the lesions, with infiltration of 
the derma and slough of its superficial layers ; or by extensive crust- 
ing, and even subsequent ulceration. 

In all varieties of pemphigus the lesions may be exhibited upon the 
mucous membrane of the accessible outlets of the body. 

Chronic pemphigus exhibits the greatest variation both as to its 
symptoms and as to the period of their efflorescence. There may be a 
week or a month of immunity, followed by benign relapses or by ma- 
lignant and rapid recurrences. The bullae may form upon an unaltered 
or a deeply hyperaemic skin, in all sizes from that of a pea to that of 
an orange, invading the skin and mucous surfaces including the vagina, 
the lesions at the base exhibiting the several features described above. 
The eruption is rarely generalized, and throughout the course of the 
disease not more than half a dozen lesions may at any moment be vis- 
ible upon the surface of the skin. Their contents may be removed by 

j evaporation, absorption, or rupture, leaving a crust the color of which 
is largely determined by the contents of the bleb. 

The areola, which may or may not be present in the several forms 

j here described, is commonly narrow, and is fully developed only when 
the bleb is mature. The separate lesions may persist for days, or may 

' rupture at an earlier period, leaving behind a superficial excoriation 

I which after healing exhibits pigment. 

The intercurrent disorders in the several forms of the disease desig- 
nated may be numerous, death occurring from septicaemia, exhaustion 



416 INFLAMMATIONS. 

(especially when a deep slough results, as in pemphigus gangrsenosus), 
and lymphangitis, the neighboring vessels and glands exhibiting evi- 
dence of the toxic effects produced by the cocci present. In some cases 
the general symptoms are absent or are insignificant, and the subjective 
sensations are limited to a slight feeling of burning or of tension. In 
other cases the blebs project from the affected surface and are well dis- 
tended ; in still others they are flaccid, the roof partially collapsing 
upon the serous, purulent, or bloody contents. The crusts which form 
are rarely bulky; they are more commonly dark colored and thin. 

Pemphigus Prtjriginosus is a name applied to that grave form of 
the disease in which the lesions give rise to an intense pruritus. As a 
result of the scratching induced by the pruritus they are torn, exco- 
riated, and commingled with the crusts and exudations of an arti- 
fically engendered eczema. If the itching be severe, the vesico-bullge 
may be so torn as to be difficult of recognition. Several of the malig- 
nant and intermediate forms may terminate fatally. 

Pemphigus Foliaceus. — Pemphigus foliaceus is a rare variety of 
dermatosis which may originate in one of the common dermatoses or in 
a grave form of pemphigus chronicus, or may, at the onset, present 
characteristic features. Hallopeau and Fournier have reported cases 
which began as a dermatitis herpetiformis. The lesions are flaccid 
bullae, which are developed without a perceptible preexisting exanthem, 
and which speedily rupture and discharge their ill-conditioned contents, 
leaving beneath an excoriated, reddish or purplish, and at times inflam- 
matory surface. Often the blebs are so poorly defined that the epidermis 
seems scarcely raised from the tissue beneath, the condition resembling 
that of the skin to which a blister has been applied, with the result of 
imperfect vesication. The contents, at first pellucid or lactescent, 
become later purulent or sanguinolent. When rupture of the blebs 
occurs there form yellowish-brown crusts which acquire a feeble attach- 
ment to the centre of the floor of the original chamber, while the edges 
remain free; these edges, visible over the affected surface, in poly- 
cyclical or irregular outlines, incompletely hiding the raw and sodden 
epidermis, present a characteristic picture. 

The disease spreads gradually until it becomes symmetrical and 
universal, a peculiarity which marks it as unique among the pem- 
phigoid eruptions, and which, in a striking degree, distinguishes it 
from pemphigus vegetans and from pemphigus acutus. As the disease 
advances the patient lies in a pitiably helpless condition, the remaining 
epidermis being completely undermined by the serum exuded, in 
places exposing large denuded areas of skin in a condition of inflam- 
mation of a low grade. Even, however, when the disease is fully 
generalized the appetite and bowel-function are at times unimpaired. 
In its later stages, after it has become generalized, the pemphigoid 
origin of the disease is not always easy of demonstration. In these 
instances large masses of greasy scales are exfoliated from the surface, 
the moisture proceeding from which is scarcely sufficient to attract 
attention. 

The disease affects the mouth and throat, denuding the mucous sur- 
faces of the epithelium. The scalp becomes affected, as also the covered 



PEMPHIGUS. 417 

portion of the body. The hairs remain attached for a long time, but 
eventually they are completely swept away. Over the face, at first 
merely reddened and scaling, occur retractive processes w T hich at times 
produce ectropion and consequent conjunctivitis. Over the body, 
especially at points pressed upon when reclining, profound ulcerations 
may destroy the deep skin. The palms and soles are infiltrated and 
fissured rather than the seat of much exudation. The nails are com- 
monly furrowed and distorted ; occasionally they are shed. The sub- 
jective sensations are those of burning, smarting, and soreness, rather 
than of itching. If the patient be kept in the continuous water-bath, 
though the disease be not thereby ended, the comfort of the sufferer is 
admirably secured. 

There may be no fever, or there may be a rise of body-temperature 
with recurrence of lesions which, in a late stage of the disease, appear 
in the sites of those which have been very imperfectly followed by 
attempts at repair, a thin and glazed epidermis forming, in cases of 
chronic type, in the sites of former bullae. In other cases the tempera- 
ture remains above normal for weeks at a time, especially in advanced 
stages of the disease. The malady may complete its course in a few 
months or may persist for years, and though not necessarily, yet is 
unquestionably fatal in the majority of cases. Death usually results 
from exhaustion ; occasionally an intercurrent pneumonia or diarrhoea 
concludes the history. 

Pemphigus Neonatorum. — The disease to which this name is given 
should not be confused with pemphigus acutus (described above), 
which may occur both in the newborn and in young adults. Pem- 
phigus neonatorum is a term which describes an affection observed 
exclusively in children. The lesions are ill-developed bullae, which 
appear soon after birth in cachectic infants that have been subjected to 
unfavorable hygienic influences. The eruption usually occurs about 
the lower portions of the trunk, as these are the regions requiring most, 
and, in these unfortunate beings, receiving least care with respect to 
cleanliness. In some cases children healthy in appearance are suddenly 
seized with an attack, the skin, according to Fox, becoming livid, the 
bullae being surrounded with dark areolae, and ulcers forming as a result 
j of gangrenous complications. These are probably cases of infection 
; with pyogenic cocci in ill-nourished infants, where the reaction of the 
i skin is expressed in a bullous rather than in a pustular efflorescence. 
j The subjects usually perish in a few days, but they may survive if 
I speedily provided with a hygienic environment. Infants thus affected 
are to be carefully distinguished from those suffering from inherited 
j syphilis and exhibiting a bullous svphiloderm on the body. 

The Inherited Form of Pemphigus described by Goldscheider, 
Legg, and others, most often noticed in summer, spring, or autumn, 
rarely in winter, is considered under the title of epidermolysis bullosa 
hereditaria. (See page 426.) 

Pemphigus of Young Girls (Pemphigus Vikgintjm). — This disorder, 
described by Hardy 1 is characterized by the appearance upon the 
skin of oval or rounded spots of a reddish or rosy hue ; upon these 

1 Traits prat, et descript. des Mai. de la Peau, Paris, 1886, p. 268. 
27 



418 INFLAMMA TIONS. 






spots there later develop vesico-bullse of different sizes, which it has 
been suspected are, in some subjects, instances of feigned eruption 
(q. v.). The subjects of the disease are between the fourteenth and the 
twentieth year of life, unmarried, and usually menstruating irregu- 
larly. Others have described a "pemphigus hystericus," "to be recog- 
nized in hysterical persons of the same class, alternating or correspond- 
ing with hysterical attacks, the eruption not uniformly disposed over 
the surface, and being transitory in duration, disappearing with relative 
rapidity and leaving no cicatricial traces of its existence. Unna dis- 
misses this affection from the category of true pemphigus. 

Pemphigus Vegetans (Erythema Bullosum Vegetans). — Neu- 
mann 1 was first to describe and furnish illustrations in color of a dis- 
ease to which he gave this name, and which has since been studied by 
a number of observers. Crocker, 2 of London, published an excel- 
lent monograph giving tabulated results in some eighteen cases ; and 
at the meeting in 1891 of the American Dermatological Association 
in Washington one of us 3 read a full account of the first case reported 
as such in the United States, the patient having been seen in connec- 
tion with Duhring, of Philadelphia. 

The onset of the disease is marked by languor, malaise, and ill- 
defined symptoms of impaired health, after which the morbid symptoms 
may first be declared in the mouth or the skin. In the former region 
white patches, which are ill-developed blebs, are visible upon the mu- 
cous surface. The detached membrane forming each spot is finally 
loosened and leaves behind equal-sized excoriated patches, which pro- 
duce extreme soreness of the mouth, and which as some heal are 
succeeded by others. In severe cases they render mastication and 
deglutition exquisitely painful ; and in patients in whom this becomes a 
prominent feature of the case the nutrition of the body is seriously 
impaired. 

The skin-lesions may precede or may follow those in the mouth. 
They are commonly first seen in women about the vulva, spreading 
over the anogenital region as closely set bullae covered with a mucoid 
whitish secretion, the features thus strongly resembling the appearance 
of condylomata of the same region. In connection with the mouth- 
lesions, the suggestion that syphilis is present is very striking, and 
has led to this error of diagnosis in a large number of instances 
reported by those not expert in diagnosis. The bullous efflorescences, 
which at first resemble those of other forms of pemphigus, speedily 
exhibit in the site of their production vegetating masses, the change 
from the bleb to a fungoid papillomatous growth being scarcely appre- 
ciable. The lesions tend to become grouped about the axillae, the 
circle at the root of the neck, the bend of the elbows, the hands, the 
feet, and the scalp, but they have no tendency to become universal, 
even when extensive. A singular change in the skin, where typical, 
well-formed bullae have developed and healed, is a deep pigmentation 
in puncta resembling comedones, with pin-point-sized verrucoid eleva- 

1 Vierteljahr. f. Derm. u. Syph., 1886, Band xiii. 

2 Pemphigus Vegetans (Neumann). London, 1890. 

3 Jour. Cutan. and Gen.-Urin. Dis., Nov. and Dec., 1891. 



PEMPHIGUS. 419 

tions of the surface. In some regions the sequence of the closly packed 
blebs, followed by vegetating masses, resembles that seen in pemphigus 
foliaceus, in which, especially over the back after long decubitus, there 
form large, granulating erosions, exquisitely painful, and hastening the 
patient to the end. The disease progresses in unmistakable accessions 
of aggravation and improvement, lasting for months and occasionally 
for years. It is in the majority of cases eventually fatal. A few cases 
have been reported as cured. The authors have had two cases present- 
ing typical features of pemphigus vegetans in which recovery was com- 
plete after two and four months, respectively, of treatment. In both 
cases, however, the eruption appeared a few weeks after vaccination, and 
was evidently the result of an acute, instead of a chronic, toxaemia. 
Variations occur, chiefly in the degree of febrile temperature, probably 
always reactive ; in the severity of the buccal lesions ; and in the extent 
of the eruption. 

Etiology. — The causes of pemphigus are obscure ; yet the connec- 
tion of many varieties of the disease with changes in the trophic nerves 
and nervous centres is established by sufficient proofs. It is well 
known also that traumatisms and lesions of the cord have been fol- 
lowed by bullous efflorescence upon the body-surface. At the same 
time (as Kaposi has well shown), on the one hand, blebs from these 
demonstrable causes never resemble the portraits distinguishable in 
the varieties of pemphigus ; and, on the other hand, there is no uni- 
formity among lesions, either as to anatomical site or other features, 
in the spinal changes to be recognized in pemphigus with a fatal issue. 
Further, of nine autopsies of bodies dead of pemphigus examined by 
Kaposi and Weiss, in only one w T ere changes found in the cord (diffuse 
sclerosis). The view that these dermatoses are instances of infective 
trouble is, therefore, gaining ground, and it is quite probable that 
future investigation will demonstrate that both the cutaneous and the 
nerve lesions are the results of a toxic agency operating with morbid 
results upon each. 

Pemphigus is more frequently encountered in males, and among 
these in infancy and childhood, because the powers of resistance at a 
tender age are inferior to those of a maturer epoch. The disease is 
often observed in debilitated patients who are variously described as 
suffering from " nervous prostration, " mental worry and exhaustion," 
"neurasthenia," " general debility," visceral disorders, and impair- 
ment of nutrition. In vigorous, rosy-cheeked, strong-limbed adults 
the disease is rare. The states in which there is marked impairment 
I of bodily vigor are particularly favorable to the development of the 
disease. It occurs in hysteria and other neurotic affections, but the 
etiological relations which these bear to the disease are undetermined. 
We have observed one case of the disease in an adult in whom pem- 
phigus of typical appearance occurred after mental depression, which 
was so greatly increased by the appearance of the exanthem as to lead 
to suicide. 

There is good reason to believe that in some of its forms the 
disease is contagious. The bullous lesions, however, seen in syph- 



420 INFLAMMATIONS. 

ilis, lepra, and other similar disorders should not always be here 
included. 

The contents of the bullae of acute pemphigus were found by Gibier, 
in 1882, to contain bacteria. His observations were confirmed by 
Vidal and Roeser. Demme, 1 in 1886, found cocci both in the con- 
tents of the bulla} and in the blood. Whiphouse 2 found diplococci 
resembling those described by Demme ; and through culture and inocu- 
lation-experiments has furnished strong presumptive evidence in favor 
of the bacterial origin of the disease. Pernet and Bullock 3 have 
recorded a number of fatal cases which occurred in butchers, the 
origin of which was traced to a local wound-infection. Other observers 
have searched in vain for a specific micro-organism of pemphigus either 
in the bullae or in the blood. 

Pathology. — Anatomical changes in the spinal cord have been 
recognized in pemphigus, as explained above, but in many cases 
careful search has failed to discover such changes. Dejerine and Leloir 
found in a case of pemphigus changes in the peripheral nerves due to 
degeneration. 

Both in the bullae and in the blood there is a marked increase in the 
number of the eosinophilous cells. In this respect pemphigus corre- 
sponds closely to dermatitis herpetiformis. The increase of the eosin- 
ophilous cells in both affections has been assigned to the effect of an 
irritant upon the nerve-centres ; but more recently these cells have 
been found abundantly in vesicles produced artificially upon the sound 
skin of a healthy individual, and it is doubtful if any especial signifi- 
cance can be attached to them. 

Most of the bullae are superficially situated between the rete and 
the horny layer or in the upper part of the rete. They may be the 
result of an inflammation in the corium, but more probably are due 
to a mechanical separation of the rete-cells by a sudden effusion of 
fluid from the vessels of the derma, the papillae becoming at the same 
time markedly ©edematous. Unna, describing chiefly the final stage 
of chronic pemphigus, found extensive and deep infiltration of vessels 
in the cutis. The lymph-vessels and lymph-spaces are dilated chiefly 
at the margin between the cutis proper and the papillary body. The 
ridge-net is hypertrophic, containing mitoses, a normal granular layer, 
and a horny layer varying in thickness. In pemphigus foliaceus the 
ridge-net is flattened, and the suprapapillary layer is reduced to a 
minimum, so that the altered corneous layer stretches almost imme- 
diately above the heads of the oedematous papillae. In general the 
©edematous epithelium is softened, and the prickle-borders and the 
interspinous spaces disappear. The epithelial cells of the coil-glands 
are swollen ; that of the ducts to a less extent. The epithelial linings 
of the hair-follicles disappear in time with the hairs. The entire process 
points to a persistent vascular paralysis with dilatation especially of th§ 
subpapillary lymph*- vessels and an oedematous swelling of the constit- 
uents of the skin, denser in the connective tissue, and accompanied 

1 Vierteljahr. f. Derm. u. Syph., 1886, p. 636. 

2 London Lancet, May 2, 1896. 

3 Brit. Jour, of Derm., 1896, pp. 157 and 205. 



PEMPHIGUS. 421 

with softening of the epithelium. The hairs and sebaceous glands 
play a purely passive part. 

Diagnosis. — From what has preceded, it will be inferred that pem- 
phigus is a name given to a disease, and not merely to bullous lesions 
upon the surface of the skin. It is of importance to remember this 
fact, as several authors have used the term in a purely descriptive sense, 
the truth being that bullae are manifestations of several disorders, 
including syphilis, lepra, herpes iris, and erythema multiforme. 

At the outset the blebs of pemphigus can scarcely be differentiated 
from those of other diseases. It is necessary for the recognition of the 
malady that consideration be had of all the cutaneous and other phe- 
nomena present in the disease. In syphilis blebs are rare in the 
adult, and relatively more frequent in infants hereditarily diseased. In 
infants the blebs are usually seen at birth, often upon the palms and 
soles, and are frequently superimposed upon an exulcerated base. The 
coexistence of mucous patches of the mouth, the vulva, and the anus 
with the other characteristic lesions and signs of grave cachexia, will 
usually indicate the nature of the disease. The cutaneous symptoms 
of infants thus affected are improperly designated as pemphigus. Such 
an eruption is a bullous syphiloderm. 

In the bullae of lepra there is usually coexisting cutaneous anaesthe- 
sia, and the involution of the bleb is followed by a strikingly char- 
acteristic atrophic patch, usually pigmented and insensitive. In pem- 
phigus foliaceus the extraordinary and usually generalized desquamation 
which ensues is sufficiently distinctive, though it must be borne in 
mind that several varieties of pemphigus may be transformed, the one 
into the other, by well-nigh insensible gradations. Among its graver 
forms susceptible of such transformation may be named impetigo 
herpetiformis, pemphigus cachecticus, pemphigus diphtheriticus, and 
pemphigus pruriginosus. 

In herpes iris the lesions are more vesicular than bullous and much 
more transitory ; are concentrically arranged and vary in color ; and 
are situated more frequently upon the extremities, especially the backs 
of the hands. The bullous lesions occasionally seen in urticaria and 
erythema multiforme are to be recognized by the other characteristic 
symptoms of these diseases ; in the former, more particularly, by their 
intermingling with typical wheals, and in the latter by the location of 
the eruption and its climatic or seasonal significance. Some of the 
reported contagious forms of pemphigus, epidemics of which have been 
described by Besnier, Hervieux, and other French authors, were possi- 
\ bly, as Duhring suggests, instances of impetigo contagiosa. This infer- 
1 ence is sustained by the frequent allusion of the writers named to the 
" varicellaform " appearance of the lesions. 

In a large proportion of cases pemphigus vegetans has been mis- 
taken for syphilis, the close grouping of the lesions about the anogenital 
region, and their striking resemblance to condylomata, taken in con- 
nection with the presence of erosions of the mucous membrane of the 
mouth, being the grounds for error. With care this blunder can usually 
be avoided. However closely packed together may be condylomata of 
this region, they rarely spread, as does pemphigus vegetans, beyond the 



422 INFLAMMATIONS. 

regions adjacent to the mucous outlets ; while the bullae of pemphigus 
vegetans, when the disease is fairly advanced, are not only exceedingly 
numerous and closely packed together, but they spread also beyond 
— high toward the pubes and low over the inner faces of the 
thighs. There is commonly a history of fever, no lymphatic adenop- 
athy, and a distinct uniformity of lesions, each separate element being 
of bullous type. 

Some ingested medicaments are capable of producing bullous lesions, 
for example, potassium iodide ; such a possibility should always be 
borne in mind when establishing a differential diagnosis. Scabies in 
infants and older children is occasionally characterized by the forma- 
tion of blebs, in which case the other lesions present, as also a history 
of contagion and the discovery of the parasite, will point to the real 
nature of the disease. 

Lastly, the external application of cantharides, mezereon, the stronger 
acids, alkalies, and other chemicals may be followed by blebs produced 
either by accident or by intention with a view to feigning disease. The 
intentional production of such symptoms is usually effected upon the 
anterior faces of the lower extremities, regions within easy reach 
of the right hand. Erysipelas and dermatitis calorica are also affec- 
tions in which blebs appear, always, however, of minor significance 
as compared with the other symptoms of disease present. The 
same may be said of the bullae which form upon a gangrenous integu- 
ment. 

Treatment. — The internal treatment of pemphigus is a matter of 
importance, as will be suggested by even a brief consideration of the 
constitutional states in which it occurs. Jonathan Hutchinson, of 
London, 1 distinctly asserts his belief that "arsenic is a specific for the 
state of health upon which relapsing pemphigus depends." In many 
years' trial of this remedy he declares that, in his own practice, he 
has never recorded a single failure, though he makes exception, prop- 
erly, of many infantile cases supposed to be syphilitic. This remedy 
is certainly a valuable one, but it should be employed with caution 
and in accordance with the rules prescribed in the chapter on Psoriasis. 
Kaposi, however, declares that he has been unable to obtain favor- 
able results from its employment. Iron, quinine, ergot, strychnine, 
and the mineral acids are indicated in many cases, in conjunction with 
a nutritious diet. Cod-liver oil and the malt preparations on the 
market should not be neglected. Not infrequently the treatment 
should be directed to the relief of the anomalous performance of the 
sexual function in women, as pemphigus has been found to occur in 
the hysterical and chlorotic states common as a result of functional 
disorder. 

The local treatment of the lesions should consist, first, in puncturing 
each bleb with a fine needle, in order to give exit to its contents, which 
should carefully be removed from the skin with the aid of cotton- wool. 
Then the parts are to be wholly enveloped in an antiseptic wet dress- 
ing, or freely dusted with a powder, such as zinc stearate or borated 
talcum. When there is considerable pyrexia, with heat and distress 

1 Lectures on Clinical Surgery, London, J. & A. Churchill, 1878, p. 49. 






HYDRO A. 423 

in the skin, the affected surface may be treated as in acute eczema, 
with oleated lime-water, containing opium or dilute hydrocyanic acid 
in some such proportions as those already detailed. 

The ordinary lead-and-opium wash, with or without the addition of 
zinc oxide, will also answer a good purpose. The continuous hot 
water-bath still enjoys among experts the highest favor in the treat- 
ment of the grave forms of pemphigus. Kaposi kept a patient day 
and night for eight months with his body thus immersed, to the great 
advantage of the invalid. This continuous bath is often impracticable 
outside a large hospital ; but in cases of grave pemphigus the continu- 
ous hot water-bath has been employed in private practice with the hap- 
piest results. 

In pemphigus vegetans internal treatment is symptomatic, usually 
along the line of elimination and support ; locally, the continuous bath 
affords speediest relief. If this cannot be obtained, the lesions should 
be cleansed thoroughly and dressed with antiseptic lotions or ointments, 
or dusted with borated, salicylated, or camphorated powders. The 
numerous scalp-lesions require cutting short the hairs of the head in 
order to make applications. Alcoholic stimulants are in most cases 
essential. 

Prognosis. — The prognosis in mild cases of pemphigus, though 
much less grave than in the malignant forms of the disease, should 
always be formulated with caution. Unlike several of the diseases 
heretofore considered, the affection is one not frequently encountered 
in persons of fair general health. The constitutional condition of the 
patient must carefully be considered ; it should not be forgotten that 
the disease is not only one liable to relapses, but also is one in which 
the graver may succeed the more benign manifestations. A flaccid 
summit of the bleb, sanguinolent or ichorous contents, an abundant 
efflorescence, and a rapid succession of new, after the involution of 
more ancient, lesions, are in general unfavorable symptoms. The same 
may be said of degeneration of the floor of the bleb after rupture and 
discharge of its contents. 

HYDROA. 

(Gr. vtiup, water.) 
(HlDROA.) 

The term Hydroa was once extensively used as a designation of 
cutaneous disorders characterized by the occurrence of a bullous 
exanthem, the blebs being associated with erythematous lesions and 
productive of subjective sensations of itching. But since it is no 
longer employed by the best authors as a title of disease, it is here 
set down merely in order to enumerate some of the affections liable 
to be confounded under the title. The Herpetiform Hydroa of 
T. Fox ; the Dermatitis Herpetiformis of Duhring ; the Herpes 
Circenatus Bullosus of Wilson ; the Hydroa of Quinquaud ; the 
Herpes Gestationis of Bulkley ; and the Pemphigus Pruriginosus 
of Chan sit and Hardy, are included by some authors under the name 



424 INFLAMMATIONS. 

hydroa. According to Quinquaud, the essential symptoms of hydroa 
are : a primary vesico-bullous exanthem ; a rapid evolution of symp- 
toms ; the termination of the disorder within two months as a maxi- 
mum ; the occurrence of pruritus in the active periods of the disease ; 
and the recognition of varieties — pemphigoid, impetiginous, vesicular, 
circinate, regional, and of a form implicating the mucous surfaces. 

Crocker describes a group of diseases by this name, " standing mid- 
way between erythema multiforme and pemphigus." The most of 
them, even on the showing of French writers including Bazin, can 
without difficulty be assigned to the one class or the other. 

Of the three varieties of hydroa proposed by Bazin, Hydroa Vesi- 
culeux is identical with the Erythema and Herpes iris of Bateman, 
and Hydroa Bulleux is a phase of Dermatitis herpetiformis. As a 
result of recent observations Hydroa vacciniforme would seem entitled 
to consideration as a distinct disease. 

HYDROA VACCINIFORME, SEU JESTIVALE. 

(Hydroa Puerorum.) 

This form of hydroa, first described in 1855 by Bazin, has been 
recognized only recently. Hutchinson, Hauford, Jamieson, Boeck, 
Crocker, 1 Bowen, 2 Graham, and others have seen and described a number 
of cases of hydroa vacciniforme. 

Symptoms. — The disease usually begins during the first three or 
four years of life and gradually disappears during the few years fol- 
lowing puberty. With but two or three exceptions the cases reported 
have been in boys. The disease is most active in summer, the larger 
number of patients remaining free from active manifestations during 
the winter months. The direct cause in most cases is exposure to the 
sun's rays, though exceptionally warm or cold winds, or even artificial 
heat, seem sufficient to cause an outbreak. 

The eruption is symmetrical and is limited to the uncovered parts 
of the body ; the bridge of the nose, cheeks, and ears, and the backs 
of the hands being the parts most affected. Bazin, however, reported 
cases in which covered portions of the body were slightly involved. 
The authors have under observation a case (the subject of the accom- 
panying illustration) in which a new crop of vesicles and bulla? on the 
face is accompanied at times by an herpetic keratitis, the resulting scars 
interfering considerably with vision. The disease occurs in successive 
outbreaks, each of which lasts for two or three weeks. The intervals 
between recurrences in the summer may be several weeks, or so brief 
as practically to be wanting. The lesions first to appear are red mac- 
ules or elevations, upon which are rapidly formed vesicles or bulla?, 
varying in size from that of a millet-seed to that of a large pea, and 
occurring either singly or in groups like herpes ; they may coalesce. 
These vesicles may dry in a day or two, or they may rupture and form 
a crust, but many of the larger become depressed in the centre ami 

1 Diseases of the Skin, 1893. 

2 Jour. Cutan. and Gen.-Urin. Dis., March, 1894. 



HYDROA VACCiyiFORME, SEU jESTIVALE. 



425 



resemble a vaccination-vesicle. The depressed centre is black or dark 
blue, and is surrounded by a ring of fluid, while about the whole is a 
reddened areola. Some of the lesions may become purulent. The 
dark centre is rapidly converted into a thick, black crust which is very 
adherent, and which on falling leaves a depressed, reddened scar that 
eventually becomes white and practically indistinguishable from that 
of variola. The duration of an individual lesion from its beginning 
to the formation of the crust is three or four days. The time required 
for the crust to fall is variable. 

The eruption is usually preceded by some slight constitutional dis- 
turbance, and by burning or pain at the site of the lesions. Itching 
is absent, as a rule, though it was marked in Bowen's case. 

Fig. 50. 




Hydroa vacciniforme. 
HYDROA iESTIVALE, HvDKOA PuEKORUM, SUMMER PRURIGO. 

A type of eruption similar in appearance, history, and etiology to that 
of hydroa vacciniforme has been described by Unna, Hutchinson, Ber- 
liner, Graham, and others, under the names above enumerated. These 
eruptions diifer from those of hydroa vacciniforme chiefly in being 
eczematous in nature. Itching is commonly present ; macules and 
papules are more numerous than the vesicles, which are not umbili- 
cated ; and scarring is comparatively slight. The disease is found in 
girls, though less frequently than in boys. 

The Pathology has been studied by Bowen in two lesions taken 
from a single case. In the primary stage he found merely vesicle- 
formation in the middle layers of the rete. In a more advanced lesion 
he found necrosis involving the lower layers of the stratum corneum, 
the entire rete, and the corium nearly to the subcutaneous tissue. He 
concluded that the process begins as an inflammation in the epidermis 
and upper part of the corium, followed by vesicle-formation in the 
rete, and later by the necrosis described above. The necrosis is 



426 INFLA MM A TJONS. 

sharply circumscribed, and, showing through the vesicles above, pro- 
duces the black centre of the advanced lesions. Bowen further calls 
attention to the points of similarity between this disease and those of 
acne necrotica, ' or of acne varioliformis. 

According to Unna, the histological facts of the disorder are an 
oedema and cellular infiltration corresponding to a vascular area of the 
skin, the chief seat of which is the papillary body ; an utterly passive be- 
havior of the epithelium, exhibiting oedema and interepithelial blebs 
or, more commonly, elevation with serum ; and, finally, the complete 
absence of leucocytosis. 

The Treatment is unsatisfactory. To prevent recurrence the patient 
should be guarded from exposure to the sun and in some cases from hot 
or cold winds. Veils and coverings which exclude the light may be of 
service. Crocker recommends treating the eruption by opening the 
vesicles and applying iodoform in powder or in solution in ether. After 
removing the crusts with carbolized oil the surfaces may be dressed with 
an ointment containing iodoform and boric acid. 



EPIDERMOLYSIS BULLOSA HEREDITARIA. 

(ACANTHOLYSIS BULLOSA.) 






This name has been given to a rare affection or condition of the skin 
in which there is a pronounced tendency to the rapid formation of bulla? 
wherever the integument may be slightly bruised or rubbed. Cases 
have been reported by Goldscheider, Kobner, Valentine, Elliott, 1 Beatty, 2 
Bowen, 3 and others. 4 In the majority of cases reported the condition 
had existed from infancy or early childhood, and there was a clear his- 
tory of heredity. Valentine reported eleven cases which occurred in 
four generations of the same family. 

The general health of individuals thus affected may be excellent and 
the skin remain sound so long as it is subjected to no irritation, but in 
some cases very slight causes (the pressure of a shoe in walking ; the 
grasping of a firm substance, such as the handle of a hammer ; the 
friction of suspenders or waistband) are sufficient to cause the appear- 
ance of firm, tense, blebs at the site of the irritation. Such bulla? 
vary in size from that of a small pea to that of a walnut. They 
often last some days, having a firm roof-wall ; are usually more or 
less painful, especially after rupture ; and disappear without leaving 
either pigmentation or scar. The predisposition to the formation of 
new bulla?, however, remains indefinitely. In Bowen's case the bulla? 
were often hemorrhagic in type and were followed by pigmentation 
and scarring. 

Histological studies of the lesions have thrown little light on the 

1 Jour. Cutan. and Gen. -Urin. Dis., Januarv, 1895; Ibid., 1899, p. 539; and N. 
Y. Med. Jour., April 21, 1900. 

2 Brit. Jour, of Derm., 1897, p. 301. He gives a resume of all previously reported 
cases. 

3 Jour. Cutan. and Gen. -Urin. Dis., 1898, p. 253. 

4 Cf. Kona, Arch. f. 'Derm. u. Syph., 1899, Bd. 1., S. 339; Russell, Jour. Cutan. 
and Gen. -Urin. Dis., 1900, p. 405 ; and Colombini, II Morgagni, 1900, No. 10. 



EPIDERMOLYSIS BULLOSA BEUEDlTARIA. 427 

etiology and pathology of the process. Elliott examined portions of 
apparently normal skin from one of his patients, and found in all the 
sections a granular degeneration of the basal layer of rete-cells and fre- 
quently of adjoining cells. The changes were most pronounced in the 
interpapillary portions. This condition permits a serous effusion to 
separate rapidly the rete from the papillary body and produce bullae. 
Elliott suggests that the disease is due to an excessive irritability of the 
cutaneous vascular supply, which responds to such slight stimuli as 
ordinary friction of clothing. The lower rete-cells are in consequence 
constantly bathed in more or less serous transudation, and degeneration 
results. 

No treatment has been found capable of insuring relief. 



PLATE VII, 





Purpura Due to Copaiba. 

(From a painting.) 



CLASS III. 
HEMORRHAGES 



PURPURA. 

(Gr. iroptyvpcoz, purple.) 

Hemorrhage into the skin may result from undue intravascular 
pressure, as in violent effort with extraordinary demand upon the circu- 
latory system. It may occur with a normal intravascular pressure 
when there is lessened extra vascular atmospheric pressure, as after ordi- 
nary exertion in high altitudes. It may result from disease of the 
vascular walls (as in malnutrition). It may result also from lack of 
support of the vessels due to various disorders of perivascular tissues, 
as where the epidermis is artificially removed, or where an abscess-cavity 
is evacuated of pus and the sac immediately fills with blood. It may 
be due to traumatism of the vascular wall. The discolored patches 
which result from contusions of the surface of the body are illustrations 
of this condition. 

Purpuric eruptions occur in many and varied constitutional condi- 
tions. They are seen in the course of measles, scarlatina, variola, 
typhoid, and other specific fevers ; in septicaemia ; in toxaemias due to 
the iodides, bromides, copaiba, belladonna, quinine, and other drugs, or 
to other articles against which the individual has an idiosyncrasy or 
which he does not properly digest and assimilate ; in rheumatic and 
gouty disorders ; in the cachexias of renal, tubercular, malignant, and 
other diseases ; and in functional and organic disorders of the nervous 
system. 

In short, purpura occurs in such a variety of conditions that it must 
be considered as a symptom of these conditions, and not as a distinct 
disease. Moreover, its relation to these constitutional disturbances is 
not well understood, and a satisfactory classification of the different 
forms of purpura based upon their etiology or pathology is not possible. 
As a matter of convenience the cutaneous hemorrhages are grouped 
according to the predominating symptom into simple, rheumatic, and 
hemorrhagic purpuras. These groups are not sharply divided, however, 
but merge the one into another. 

Symptoms. — The lesions of purpura have the following character- 
istics in common : They all are due to escape of blood into the tissues ; 
they do not fade under pressure ; they usually appear suddenly ; at first 
they are of a bright- or deep-red color, which in a few hours or days 
changes to the duller and darker shades of red, purple, and brown, 

429 



430 HEMORRHAGES. 

which in turn, beginning at the centre, slowly fade through various 
shades of brown, green, and yellow to the normal color of the skin. 
On the lower extremities the pigmentation sometimes persists for years. 
According to their shape, size, and arrangement, the lesions of purpura 
are designated as petechije which are pin-point- to small coin-sized, 
usually well-defined macules, sometimes situated about the hair-follicles ; 
ecchymoses, which are like petechia?, except that they are larger and 
more irregular in shape and in distribution, sometimes covering the 
entire surface of a limb ; and vibices, which are linear and band-like 
arrangements of ecchymoses. Occasionally the hemorrhage takes the 
form of bullae (bulljs hemorrhagica), or of nut- to egg-sized, and 
even larger, tumors (ecchymomata). At times purpura is seen in the 
form of minute papules. In addition to the clinical forms above 
described, purpura may appear as a complication and modification of 
the various lesions of erythema multiforme, urticaria, and other cuta- 
neous diseases. 

Purpura Pulicosa is the result of the traumatisms produced by 
fleas, lice, and bugs. The lesions are punctiform and are due to the 
welling up of blood into the minute punctured wound, which is sur- 
rounded usually by a hyperaemic halo, the result of the irritation. 
When the areola fades the central hemorrhagic point usually persists 
for a brief time. The disease is characteristically manifested upon the 
filthy skins of individuals long bitten by bugs and covered with 
excoriations and dark-colored crusts the result of scratching. Such 
cases are often pronounced scorbutic. 

Purpura Simplex. — In this form of cutaneous hemorrhage, pinhead- 
to pea-sized, light-red to dark-purple petechia? and small ecchymoses, 
usually multiple and symmetrical, a few at a time or suddenly in 
large numbers, appear upon various portions of the body-surface, 
chiefly over the lower extremities, and here doubtless by preference 
because of the greater effect of gravity upon the column of blood. The 
lesions usually awaken no subjective sensation, and they may occur in 
persons of apparently unaltered health, though rigid examination will 
often disclose some facts having a bearing upon the etiology of the dis- 
ease. The subjects of the disorder may be asthenic, and complain of 
unwonted lassitude and malaise. The disease may last for a fortnight, 
and in exceptional cases may be accompanied by a rise of temperature. 
Lesions of this sort may be due solely to an ingested medicament, such 
as arsenic, salicylic acid, or quinine. The lower extremities may be 
covered completely with petechia? induced by ingestion of potassium 
iodide. 

Purpura Urticans is that form in which there is an irritability of 
the skin sufficient to produce wheals and other urticarial lesions that 
are accompanied by itching in various degrees and that have a pur- 
puric hue in consequence of circumscribed cutaneous hemorrhage. 

Purpura Rheumatica (Peliosis Eheumatica, Arthritic Pur- 
pura, Schonlein's Disease). — This variety of purpura, which has 
a striking analogy to erythema multiforme, is probably an exaggerated 
form of some of the conditions recognized under that title. It is pre- 
ceded by the usual febrile or other premonitory symptoms associated 



PURPURA. 431 

with arthritic pains, especially of the knees and ankles, which may 
become swollen or be affected with a hydrarthrosis. In a few days 
petechial to ecchyrnotic, light-red to dark-purplish maculations appear 
upon the extremities, the trunk, or the entire surface of the body, fade- 
less under pressure, and usually with coincident relief of the arthritic 
pain. The subjective sensations are ordinarily trivial. In a fortnight 
the eruption may subside, its color undergoing the usual variations 
from greenish to orange and light yellow; but relapses are common in 
the course of weeks, with recrudescence of the fever, return of 
rheumatoid symptoms, and progressive asthenia. The purpuric spots 
sometimes make their appearance regularly in the afternoon or evening, 
sometimes daily and often with several days' interval, accompanied by 
pain, stiffness, and swelling of joints. The arthritic symptoms are 
extremely variable and may be slight or severe. While most common 
in the knees and ankles, they may appear in any joints of the body. 
Associated with the purpura and the arthritic symptoms there are often 
mild or severe gastro-intestinal disturbances. 

There are thus, in the majority of cases, three groups of symptoms, 
the cutaneous, the arthritic, and the gastro-intestinal. It is rare, how- 
, ever, for these symptoms to be equally severe in any one case, one or two 
I of the groups being usually but slightly or not at all apparent. Fre- 
quently one group follows another. Thus, the arthritic pains may sub- 
side before the appearance of the purpura, or the reverse may be true. 
Throat-lesions, acute circumscribed oedema, and urticaria are often 
seen with one or more of the groups of symptoms above described. 
! The intimate relation of purpura rheumatica to erythema multiforme 
j is discussed in the pages devoted to the latter disorder. Cases are 
'• described in which there was coincidence of purpura rheumatica with 
: renal hemorrhage, albuminuria, and gangrene of the soft palate. Cases 
j are also on record in which there were cardiac involvement and grave 
] disorders of other viscera. In Hemophilia, a disease occasionally of 
hereditary origin and characterized by the facility with which trivial 
traumatisms of the body-surface are followed by incoercible hemor- 
rhages, purpura may be the first signal of the predisposition. A young 
man with purpuric lesions of both lower extremities, but otherwise 
apparently in good health, presented himself at the dermatological 
clinic. There was at the time no suspicion of haemophilia, but two 
weeks later as the result of a vaccination he bled continuously for eight 
days. 

The disease occurs in both sexes, though more often in young 
women, and it is to a certain extent influenced by the changes of climate 
and season. Its diagnosis, in consequence of its marked characteristics, 
i coincidence of petechias and ecchymoses with rheumatoid pains, is 
readily effected. Duhring calls attention to the danger of confounding 
the disease with the macular syphiloderm, the lesions of which, how- 
ever, when relatively recent, fade under pressure. 

The prognosis is in general favorable, though the condition may 
'persist for long periods of time, and may, in rare cases, terminate 
fatally. The final result depends naturally upon the constitutional 
affection with which the purpura is associated. 



432 HEMORRHAGES. 

Purpura Hemorrhagica (Morbus Maculosus Werlhoffii 
" Land-scurvy "). — This disorder is usually ushered in with phe- 
nomena of a febrile character, accompanied by symptoms of general 
depression. Subsequently ecchymoses appear upon the extremities and 
the trunk, both spontaneously and at points at which the integument 
has specially been subjected to pressure and friction. Often petechia 
appear simultaneously upon the nasal, laryngeal, buccal, aud other 
mucous surfaces, which may also be the seat of exhausting hemor- 
rhages, resulting rarely in fatal collapse. A symptomatic fever is 
usually awakened. The disease occurs equally in the robust and the 
feeble of all ages, and, though commonly a sporadic affection, it may 
assume an epidemic form. Purpura hemorrhagica is slow in its course, 
but, as a rule, terminates favorably after the lapse of several months. 
In some instances the general symptoms are those of typhoid fever ; and 
hemorrhage from the mucous surfaces, including those of the stomach 
and intestines, may be severe. In yet severer cases, to which the name 
Purpura Fulminans is applied, the symptoms are those of septicaemia 
or of other acute and severe infection. In these cases extensive internal 
hemorrhage may be followed by death. Many of the severer cases of 
hemorrhagic purpura are undoubtedly due to infections the exact nature 
of which is not understood. 

The lesions commonly appear first on the upper extremities, then 
over the trunk, and finally over the lower extremities. They are 
usually dark red or purplish in hue, varying in size from that of a pin- 
head to that of a bean, but they may be of the size of the palm. 

Hemorrhagic purpura is distinguished from purpura scorbutica, or 
"scurvy," by the absence of distinctive premonitory symptoms of the 
latter disease which always occurs among those suffering from improper 
alimentation, vitiated air, and lack of exercise. 

Purpura Scorbutica (Scurvy). — This disorder is peculiar to those 
who are compelled to subsist for lengthened periods of time on improper 
diet, more particularly that from which fruit and fresh vegetables are 
excluded; to respire vitiated air; and to endure such confinement as 
precludes the possibility of duly exercising the body. The disorder is, 
hence, more common among sailors, prisoners, Arctic voyagers, and men 
similarly situated. 

The cutaneous lesions are, as in so many other forms of purpura, 
preceded by an almost characteristic sense of languor and depression. 
One or several joints may then enlarge. There may be a distinct 
febrile action. 

The hemorrhages which result resemble those of purpura hemor- 
rhagica ; the cutaneous lesions are petechia, ecchymoses, and painful 
ecchymomata, usually first appearing on the lower extremities, that 
may fluctuate, open, and result in offensive ulcerations reaching to the 
bone. Simultaneously with the cutaneous eruptions the gums become 
involved, showing tumid, hemorrhagic, or ulcerative fungosities, 
smeared with a dirty yellowish secretion, and having a fetid exhalation. 
The subcutaneous connective tissue, muscles, fasciae, and viscera become 
involved. The disease is accompanied by febrile and other general 
phenomena of asthenia, and, when the causes are persistent, results 



PURPURA. 433 

fatally. It is, however, remediable by proper treatment, though con- 
valescence is usually tediously prolonged. 

Etiology. — It is evident that the causes of purpura must vary with 
the constitutional disturbances upon which it depends. Direct infection 
is undoubtedly the cause of many hemorrhagic purpuras. Letzerich, 
in 1889, recognized in the spots of purpura hsemorrhagica long bacilli, 
cultures from which injected into rabbits produced a purpura with 
stuffing of the hepatic capillaries by colonies of the same microorganism. 
Other investigators have since found micrococci or bacilli in the lesions 
of purpura hsemorrhagica or in the blood. These organisms have 
been cultivated and the disease reproduced in rabbits, dogs, and 
guinea-pigs by inoculations with pure cultures. The purpuras occur- 
ring in typhoid and other specific fevers are evidently due indirectly 
to infection. Other purpuras are evidently toxic in origin, as in drug- 
ingestion (particularly after the administration of potassium iodide), 
anaemia, cachexia, etc. 

The influence of the nervous system in the origin of many purpuras 
is unquestionably important. Purpura may occur in the course of 
various functional and organic disorders of the nervous system. It 
has followed severe neuralgia, over-exertion, sudden fright, a fit of 
anger, and other violent emotions. By many authors the rheumatic 
purpuras are considered neurotic in origin. Osier suggests that the 
purpuras, together with urticaria, angioneurotic oedema, and erythema 
multiforme, may depend upon " some poison — an alkaloid, possibly 
the result of faulty chylopoietic metabolism, which in varying doses in 
different constitutions excites in one urticaria, in a second peliosis rheu- 
matica, and in a third a fatal form of purpura." 

Pathology. — The hemorrhage occurs chiefly in the corium, but also 
at times in the subcutaneous tissue. The corium shows collections of 
red blood-corpuscles, and later variously sized granules of blood-pig- 
j ment which is slowly absorbed, producing the color-changes character- 
istic of purpura. The pigment may be wholly absorbed in a few weeks 
or persist for years. Evidences of inflammation are present in some 
cases, there being dilatation of the papillary vessels, with some oedema 
and perivascular infiltration of leucocytes. In a few instances endo- 
thelial proliferation and endarteritis have been noted. 

Wilson, Fox, and others have recognized lardaceous or inflammatory 
changes in the vascular walls, with embolism or thrombus in others. 
Watson Cheyne l and others have found some of the capillaries in the 
neighborhood of the hemorrhages plugged with bacilli, and colonies of 
the same in the effused blood. Leloir found in a single case coagulated 
fibrin adhering to the walls of a number of vessels of the skin. 

Examinations of the blood have shown irregular variations from 

, normal in the number and form of the blood-cells and in the quantity 

of fibrin. Micro-organisms have been found in many cases. These 

examinations, however, have not thrown much light on the pathology 

of purpura. 

Treatment. — The treatment of these various forms of cutaneous 

1 Brit. Med. Jour., September 1, 1883, p. 416. 
28 



434 HEMORRHAGES. 

hemorrhage depends upon the nature of the cause in each case. If 
this be found and removed, no other treatment may be necessary. In 
general it may be said that internally the use of ergot, of ferric chloride 
or other salt of iron, and of quinine is advisable. Oil of turpentine, 
plumbic acetate, and dilute sulphuric acid have all been employed at 
times with marked success, at others without avail, in the treatment of 
these cases. Hypodermatic injections of ergotin, 1 part to 2 of dis- 
tilled water, repeated every second day, have been followed by favor- 
able and rapid results. A generous diet, the use of wine, malt liquors, 
and even spirits, and a strict observance of the demands of hygiene, 
are often essential methods of relief. 

In the way of local treatment the gums often require an application 
of rhatany, 1 part of the extract to 50 or 60 of lotion ; or equal parts 
of tincture of cinchona and tincture of myrrh, diluted as required. 

Rest in the recumbent position is advisable, and in severe cases is 
imperative. If hemorrhage be actually in progress, the free use of 
haemostatics will be required, with local application of ice. For those 
who are convalescent from systemic disorders accompanied by purpuric 
lesions of the lower extremities, resorption of the extravasated blood 
may be hastened by the local application of stimulating spirit-lotions 
with friction ; and the pressure of the blood-column may partly be 
relieved by elastic bandaging of the extremities. 

The Prognosis has been given, as far as might be, in connection 
with each disorder named. 



CLASS IV. 
HYPERTROPHIES. 



LENTIGO. 

(Lat. lens, a freckle.) 

(Freckles, Ephelis. Ger., Sommersprosse.) 

SymptomSo — This condition is due to excessive and irregular de- 
posit of pigment in the skin, producing the pin head- to bean-sized 
spots of circinate or of irregular outline, frequently grouped and even 
confluent, which spots are commonly designated as " freckles." They 
are most frequently seen symmetrically distributed on those parts of 
the body ordinarily exposed to the light and heat of the sun and to at- 
mospheric influences, such as the face, the neck, and the backs of the 
hands in persons of both sexes. In those individuals whose bodies 
are to a greater extent similarly exposed they occur upon the chest, the 
back, and over the extremities. In other persons they may be seen 
upon parts not thus exposed, such as the penis, the scrotum, and the 
inner surfaces of the thighs, a fact which indicates that freckles are not 
always the result of the operation of the agencies noted above. They 
vary in color from light yellow, salmon, or red to the deepest brown ; 
and are most noticeable in those having red hair and a delicate skin. 
Freckles occur rarely in infancy, partly, perhaps, on account of the 
infrequency of outdoor exposure in tender years. They are usually 
seen first about the age of six to eight years. They are commonly 
observed in mulattoes, individuals of a race particularly disposed to 
anomalies of pigment-distribution. Once developed, the lesions may 
persist through life without marked alteration ; or may fade with each 
recurrence of the season of winter ; or in milder cases may disappear. 
They usually share in the atrophic changes of old age, and, when per- 
sisting to that period, may then spontaneously disappear. They are 
not the source of subjective sensation. 

Etiology. — Freckles are unquestionably produced and aggravated 
at times by the action of the light and heat of the sun, as common ex- 
perience suggests ; but it is evident that these forces must act upon a 
susceptible skin. Of a hundred sailors exposed in precisely similar 
situations on a long cruise, some of the number will uniformly be 
"tanned" and others deeply "freckled." Attention has been called 
to the occasional occurrence of lentigo in the protected parts of the 
skin. Exposure to sea-air and fog, with obscuration of the sun, is suf- 
ficient to produce the result. 

435 



436 HYPERTROPHIES. 

Pathology. — Freckles are due to an increased deposit of pigment 
in definite areas of the rete mucosum of the epidermis, never in the 
corium. The pigment accumulates densely in and about the prickle- ' 
cells, which become apparently softer and lose their spines at a later 
stage. Unna divides pigmentations of the skin into two classes : 
hemosiderosis (due to granules containing iron) ; and melanosis (due 
to pigments in which the presence of iron has not been determined). 
In lentigo no iron-reaction has been recognized. Lassar urges, with 
strong probability, that there is always a congenital predisposition to 
these pigment-formations that requires certain external conditions for 
development. 

Treatment. — The treatment of lentigines is that of chloasma and 
other pigmentations of the surface. Wertheim, of Vienna, advises : 

R Hydrarg. ammon. muriat., gr. lvj ; 3 75 

Bismuth, magister., gr. lij ; 3 50 

Ungt. glycerini, Jj ; 30[ M. 

Sig. To be applied every other night. 

Bulkley employs : 

R Hydrarg. chlor. corros., gr. vj ; [4 

Acid, acetic, dilut., f^ij; 8 

Boracis, £ij ; 2 66 

Aq. ros., f^iv; 120 M. 

Sig. To be applied night and morning, at first with gentle brushing ; after- 
ward by rubbing. 

Hardaway touches each freckle with a rather stiff needle connected 
with the negative pole of a galvanic battery, and he finds the results 
satisfactory. 

Most of the methods employed by charlatans for the removal 
of freckles depend for their success upon thorough blistering of the 
surface. Inasmuch as by this process the epidermis is removed, it is 
evident that the pigment of its cells is also removed with it, and the 
new epidermis is for a time free from blemish. But in all such cases 
the ultimate result is a deeper and more persistent pigmentation than 
that which was previously visible. 

CHLOASMA. 

(Gr. ^Aoacw, to possess a greenish color.) 

Symptoms. — In this affection the skin is either diffusely discolored 
in various shades, or the maculations occur in patches larger than 
those of lentigo, fairly well denned, and irregular in contour, the so- 
called " liver-spots." In color they vary from a scarcely perceptible 
staining of the skin that requires a strong light for its detection, to a 
deep-yellow, a yellowish-green, a chocolate-brown, or a blackish shade 
(Melanoderma). They may be idiopathic or symptomatic in 
character. 

The idiopathic varieties of chloasma are produced by all externally 
operating agencies, in consequence of which an undue afflux of blood 



CHLOASMA. 437 

is persistently determined to any portion of the skin. It is largely 
from the blood that the pigment is derived, hence the stains produced 
by the pigment are, to a certain extent at least, proportioned to the 
hyperemia, stasis, or extravasation of the vascular fluid. Among these 
externally operating agencies may be named pressure and friction (as 
over the part covered by the pad of a truss) ; traumatism (as after the 
severe scratching of the skin affected with lice, eczema, or scabies) ; 
heat (as in diffuse " tanning " of the face, or " sunburn " following 
exposure to the solar rays) ; and the toxic or irritating effect of externally 
applied substances, such as mustard, capsicum, cantharides, and other 
articles capable of producing either vesication or pustulation of the 
skin-surface. Persistent or even permanent pigmentation of the skin 
upon the face, shoulders, and bosom, especially of young women, may 
be produced by the repeated application of such topical medicaments. 

The symptomatic varieties of chloasma are the result of disorders 
either systemic or those involving the internal organs. They occur as 
either circumscribed or diffused, localized or generalized, spots, mot- 
tlings, stainings, or " masks " of the skin, and they vary in color from 
the lightest to the darkest shades. One of the most common, and at 
the same time the most marked of these varieties, is 

Chloasma Uterinum, so called because of its frequent association 
with certain physiological or pathological conditions of the uterus, both 
among married and single women. Thus, in pregnancy, sterility, hys- 
teria, chlorosis, ovarian disorders and tumors, and functional derange- 
ments of the uterus there can be observed at times a facial discoloration 
extending equably over the forehead and reaching nearly to the line of 
the hairs at the scalp, in the form of a faint or a decidedly reddish-yellow 
or deep-brownish tinge. At other times the discoloration is macular 
and asymmetrical, involving the eyelids, the cheeks, the lips, or the 
chin. When the chloasma assumes the mask-like form it is usually 
most pronounced over the forehead, but it may involve the whole facial 
region, being less distinctly defined below than above. Similarly, the 
well-known changes occur in the areola of the nipple, along the linea 
alba, and about the external genitalia. 

Chloasma (or Melanoderma) Cachecticorum is another of the 
symptomatic pigment-disorders, characterized by changes in the color 
of the integument of the subjects of tuberculosis, syphilis, cancer, 
chronic alcoholism, malaria, and other disorders. Its hue varies between 
a faintly defined yellow to a deep chocolate. 

Addison's Disease, formerly thought to be due exclusively to 
lesions of the suprarenal capsules, is of the same nature, and is charac- 
terized by a peculiar bronzing of the skin. Overbeck and Greenhow 
have shown that the capsules may be destroyed wholly without 
changes in the skin-color resulting. The pigmentation may be gen- 
eral or be partial, and in the latter case is without definite lines of 
demarcation. It is commonly most pronounced over the face and neck, 
the scrotum, the groins, the axilla, and the nipple and areola. The 
hairs become coarse and dark ; and dark or grayish-brown patches are 
at times visible over the mucous surface of the lips, the gums, and 
other parts of the mouth. The bronze or mulatto-like color of the 



438 HYPERTROPHIES. 

skin is intensified by stimulation or erosion of the cutaneous surface, 
and by exposure to light. In these cases there are generally marked 
asthenia and a feeble pulse, with anorexia and other signs of gastro- 
intestinal disorder. When the result is fatal there may or may not be 
recognized pathological alterations of the suprarenal capsules. 

The pigment when examined furnishes no iron-reaction. 

Hadra, of Berlin, reports a case of Addison's disease cured by extir- 
pation of a small apple-sized tubercular neoplasm of the retroperitoneal 
glands. A suprarenal capsule was contained in the growth. 1 

Among the cutaneous disorders capable of producing skin-pigmenta- 
tion may be named scleroderma, lepra, angioma pigmentosum et atroph- 
icum, eczema (especially e. venis varicosis), and general exfoliative 
dermatitis. 

From all the above-named discolorations, which are due solely to 
deposition in excess of coloring-matters normally existing in the skin, 
it is necessary to distinguish the various dyschromia which are owing 
to the introduction into the integument of coloring substances, either 
supplied by other portions of the body or foreign to it. Thus, in 
Icterus the bile may color the skin from a light-yellow to a dark- 
chrome shade, the duration and severity of the cutaneous symptoms 
depending upon the nature and gravity of the hepatic disease. This 
condition is frequently accompanied by pruritus in various grades of 
severity, the exact causes of which are obscure. 

Chloasma from Ingestion of Arsenic. — The administration of 
arsenic in full doses for relief of nervous disorders in adults and chil- 
dren is frequently followed by a characteristic dull-brownish or dirty- 
colored discoloration of the skin of the neck and chest. In connection 
with these arsenical pigmentations, which are in some instances obsti- 
nate and generalized, may occur palmar or plantar keratoses, as well 
as those appearing elsewhere, which may be the starting-point of an 
epithelioma. 

Argyria. — A bluish, bluish-gray, slate-colored, or bronzed colora- 
tion of the skin may result from ingestion of silver nitrate. Argyria 
is most commonly the result of the administration of the drug in the 
treatment of epilepsy, but it is said to have also resulted from the topi- 
cal application of silver-crayons to the throat, to the conjunctivae, and 
even to the skin. Under what form the silver produces this effect, 
whether as an albuminate or other salt, is not known. The deposition, 
however, occurs in the form of minute particles of the metal in the 
connective tissue of the derma. The discolorations are most evident 
upon the parts of the skin exposed to the light, as the face and hands ; 
but the chest and the lower extremities may be similarly stained. The 
connective tissue of the viscera is at times also involved, showing thus 
that the action of light is not essential to the production of the dys- 
chromia. Two cases are reported as relieved by the administration of 
potassium iodide. 

Tattooing. — By the process of tattooing mineral and vegetable 
substances are directly introduced into the corium by means of needles, 

1 Medical Week, Paris, Oct., 1896. 






CHLOASMA. 439 

for the production in the skin of various devices in colors. Individuals 
whose entire integument has been thus artificially covered with figures 
of different patterns by tattooing with indigo, vermilion, and cinnabar, 
are from time to time publicly exhibited. The results are indelible. 
Post mortem these pigments have been discovered not only in the 
derma, but also in the lymphatic ganglia nearest the site of their 
introduction. 

Anomalous Discoloration of the Skin and the Mucous 
Membranes. — Bruce 1 describes the case of a harness-maker, the gen- 
eral surface of whose body, especially the skin of the face and of the 
extremities, as well as the mucous surfaces, underwent a noteworthy 
change of color. The hue acquired was a deep and uniform cyanotic 
shade. The symptoms in this case are believed by some to have resulted 
from the employment of nitrate of silver. 

Pathology. — The lentigines, ephelides, and chloasmata are all due 
to excessive deposit of the natural pigment of the body in the rete 
musosum of the epidermis. Restoration of the normal color of the 
skin is usually proportioned to the extent and depth of the deposit, 
but the process is always very gradual. It can well be studied in the 
slow bleaching of the pigmentation of syphilitic cicatrices upon the 
lower extremities. In the dyschromias due to the introduction of 
coloring-matters foreign to the body or foreign to the skin the corium 
and the subcutaneous connective tissue are commonly stained. 

The origin of the pigment in the skin being still undetermined, 
pathologists are unsettled as to the question whether migratory pigment- 
conveying cells are responsible for the change of color in the skin or 
whether the pigment-granules themselves migrate. Kaposi, Jarisch, 
and a few others believe that pigment is formed in the rete. Unna 
believes there are two distinct kinds of pigment, not however fully 
differentiated, formed in the corium and carried through the lymphatic 
spaces to the rete. Ehrmann, 2 after much careful investigation, states 
that there are special pigment-cells, or " melanoblasts," which are formed 
in the embryo from the mesoderm. These cells perpetuate themselves, 
being thus independent of all other bodies, and are connected by long 
processes or threads of protoplasm, along which the pigment flows in a 
viscous state. The cells obtain their pigment from the haemoglobin of 
the blood. All pigment outside of these cells he considers hsematin- 
detritus. In some of these cases there is no change in the walls of the 
blood-vessels and there are no signs of blood-extravasation. 

Diagnosis. — The diagnosis of cutaneous pigment-hypertrophies is 
readily effected by observing the persistence of the discoloration under 
pressure; the absence of all symptoms of hyperemia, inflammation, 
and secondary changes in the skin, as also by the characteristic shades 
of color presented to the eye. In tinea versicolor there is usually 
slight furfuraceous desquamation, and the existence of a vegetable par- 
asite is readily demonstrated by the microscope. The rare pigmentary 
syphilide is usually seen upon the neck and shoulders of infected women 

1 Internat. Atlas of Rare Skin-diseases, 1892, vol. vi., 2 and 7. 

2 Bibliotheca Medica D. II., Part VI., W. G. Fisher & Co. 



440 



IIYPERTR OPHIES. 



in the form of yellowish to brownish maculations, often arranged in an 
irregular network. The lesion is, indeed, one of the symptomatic 
chloasmata. 

Treatment. — In all the symptomatic pigment-anomalies the indi- 
cations for treatment are presented by the disease which begets the 
cutaneous disorder. 

The local treatment of both the idiopathic and symptomatic varieties 
of the affection demands the use of external applications which will 
hasten the physiological reproduction of the epidermis, substituting thus 
new and unpigmented for old and pigmented epithelia. This process 
must also be accomplished without the artificial production of such an 
hyperemia as will tend to add to the very coloration which it is 
attempted to relieve. The substances used for the slow accomplish- 
ment of this end are borax, sulphur, tincture of iodine, potassium and 
sodium hydroxides (including the soaps of these alkalies), and the mer- 
curials. None of these substances is more generally employed than 
corrosive sublimate, which constitutes the basis of most of the cosmetic 
lotions sold in the shops. 

The following formulae are given by White 1 for use in the evening. 
The preparation in each case should be left upon the affected surface 
during the night, and be removed by a soap-and-water washing in the 
morning. They are to be used for weeks in succession, but only after 
a cautious preliminary testing of the sensitiveness of the skin to their 
action. To avoid the possibility of error, the practitioner would do 
well to order a poison-label upon all vials containing the sublimate : 



R Hydrarg. am. chlor., ) 



Bismuth, magister. 

Amyl., 

Glycerin. 



aa 3ij ; 

aa ^ss; 



aa 8 
aa 15 



M. 



R Ammon. murat., 
Aq. Colognien., 
Aq. dest., 

R Hydrarg. bichlorid., 
Acid. mur. dil., 
Glycerin., 
Alcoholis, | 
Aq. ros., J 
Aq. dest., 



3ss; 
Oss; 

gr. vj; 
fSi; 

fBJ; 

aa f gij ; 
fgiy: 



2 

30 
240 



4 

30 



M. 



aa 60 
120 



M. 



The following formulae for ointments are given by Kaposi : 



R Hydrarg. ammon., ) 
Sodse biborat., } 
01. rosmarin., 
Ungent. simpl., 

R Acid, boric, | 
Cer. albse., j 
Paraffin., 
01. amygd. chile, 



aa §ss; 



gtts. x ; 

5j; 



aa 3j; 
3ij; 

3j; 



aa 15 

30 

aa 4 



6Q 



M. 



8 
30 M. 



1 Lot. cit. 



CHLOASMA. 441 

Van Harlingen recommends : 

R Hydrarg. chlor. corros., gr. vss : 

Zinci sulphatis, ) -- ■- == 2 

Plumbi subacetat., J aa^ss, aa a 

Aq. dest.. fSiv; 120 M. 

Sig. Lotion, for external use, morning and evening. 

Other measures advised are : stimulation with alcohol, and applica- 
tion, for several hours after, of a plaster of ammoniated mercury; 2 
parts of magnesium carbonate and zinc oxide, 4 parts of pure kaolin 
and glycerin, and 10 of vaselin; chloroform, 100 parts, chrysarobin, 
15 parts (Leloir); hydrogen peroxide; diluted acetic, carbolic, muriatic, 
and nitric acids; 1 to 2 parts of salicylic acid, in paste or powder, to 
20 parts of base; and solutions of mercuric chloride in collodion, 1 part 
to 30, employed with great caution. 

The rapid removal of pigmented patches is accomplished, in Vienna, 
by covering the part with strips of linen dipped in an aqueous or an 
alcoholic solution of corrosive sublimate of the strength of 4 grains 
(0.26) to the ounce (30.), with which solution the dressing is also occa- 
sionally moistened. Vesiculation is usually accomplished in about four 
hours, when the serum is evacuated by puncture, and the detached epi- 
dermis is covered with any inert dusting-powder. The resulting crusts 
fall in about eight days. The procedure is attended with danger of 
producing in the end the precise deformity which it seeks to remedy, a 
danger explained above. 

Another method of removing tattoo-marks and pigmented nsevi, 
successfully employed by French dermatologists, consists in tattooing 
the region, previously rendered aseptic, with a solution of 30 parts of 
zinc chloride to 40 parts of water. If properly done, the resulting 
inflammation is slight, and after a few days there forms a superficial 
crust which remains about a week and then falls, leaving a slight scar 
which becomes almost imperceptible. This method calls for skill and 
care in its application in order to obtain good results and to avoid sup- 
puration and deep cicatrization. 

The internal administration of potassium iodide, recommended for 
the removal of argyria, has often failed. 

Prognosis. — The prognosis is in all cases uncertain. There is 
strong reason to believe that the local treatment of these dyschromias 
is, in the long run, ineffective. Those methods which effectually and 
brilliantly accomplish the desired end are almost invariably followed 
by deeper pigmentation than that which it was attempted to remove ; 
those operating more slowly have, probably, a less speedy, but scarcely 
more disguised sequel. It is likely that local treatment of these pig- 
mented states will ere long be abandoned. The treatment intelligently 
directed to the cause of each discoloration is that which in the end 
proves most satisfactory. 



442 HYPERTROPHIES. 

KERATOSIS. 

(Gr. icepag, a horn.) 

The term Keratosis was first applied by Lebert to hypertrophic 
lesions of the epidermis. It has since been made to include changes 
in both the epidermis and the corium, and it is employed by some 
authors in a generic sense to embrace a number of both localized and 
general hypertrophies of these portions of the skin. 

KERATOSIS PILARIS. 

(Lichen Pilaris, Pityriasis Pilaris.) 

Symptoms. — This condition may be a mere temporary functional 
disturbance of the skin, awakening no subjective sensation, inappreci- 
able by the patient and apparent only to the careful observer, or it 
may constitute a disease. Its symptoms are the occurrence of pinhead- 
sized, pointed elevations of the skin-surface that may be described as 
papules, though, strictly speaking, they are not such, but are consti- 
tuted by an accumulation of horny epithelia and a small quantity of 
inspissated sebum about the lanugo-hairs of the extensor surfaces of 
the extremities and trunk. These aggregations of material are usually 
of a dirty-whitish or grayish hue, and are pierced by a lanugo-hair 
implanted in the follicle about which the abnormal condition exists. 
Occasionally, however, the hairs are of the finer and shorter kind, and 
are often coiled in or otherwise covered by the little heaps of epithelial 
debris. The skin of the individual thus affected is generally harsh, 
squamous, and dry to the touch ; being also, in the majority of cases, 
long unwashed. The color of the quasi-papules differs also with the 
complexion of the individual ; at times the papules have a distinctly 
reddish tinge, and they are often surmounted by a scale. 

Keratosis of this type can scarcely be described as a morbid state. 
Those who seek treatment for it are readily divided into two classes : 
first, comely young women desiring to exhibit bare arms in evening 
toilet ; second, young men suffering from the delusion that they are vic- 
tims of a " disease of the blood " or of syphilis. Viewed as a whole, 
the subjects of the best types of this so-called " disease " are men and 
women of exceeding vigor, with firm, well-developed muscles and 
shapely limbs. 

Keratosis pilaris is common in skins long uncleansed by ablution, 
and this condition can thus be produced artificially. In some individ- 
uals it persists for long periods of time, and awakens no concern. In 
others, especially in children, it speedily becomes the source of pruritus, 
and each lichenoid papule may then be transformed into an urticarial 
wheal, with distinct and sometimes very annoying pricking and ting- 
ling sensations, the trouble being at once relieved by a bath in warm 
water with soap. In still other individuals, especially in adults, an 
exaggerated form of the disease can be recognized, the skin presenting 
a roughness to the touch suggestive of the surface of a nutmeg-grater, 
and exhibiting numerous fine, conical, grayish, horn-tipped filaments, 



KERATOSIS. 443 

which several dermatologists are disposed to regard as a form of ich- 
thyosis. Id the latter case there is doubtless a true hypertrophy of 
the epidermis. In the former case there is scarcely more than a me- 
chanical accumulation of effete organic material. There can be little 
doubt that the malady, simple though it be in character at the onset, 
may become the first stage of a series of chronic cutaneous disorders. 
Tilbury Fox has reported four cases, in which the disease was well 
marked, under the title of Cacotrophia Folliculorum, this name 
being employed to designate its peculiarities as to wide distribution 
over the body, its implication of the deeper portion of the follicles, and 
its congenital history. In these cases the reddish tint of the lesions is 
distinctly shown. 

Brocq, who devotes an extensive chapter to this affection, describes 
a white variety, the uncolored circumpilary papules being scattered 
over the arms, forearms, legs, and thighs, usually on the outer faces of 
the extremities, and three inflammatory types : (a) a mild form, in 
which reddish papules are disseminated among those of the " white " 
class ; (b) a form of medium intensity, in which the papules are gener- 
erally rosy-red in hue ; (c) an intense form, in which well-marked 
lesions occur over the surface of the chest, the lumbar and pubic re- 
gions, and the folds of the larger articulations. 

Keratosis pilaris on the face, as described by French writers, is 
characterized by exceedingly minute, usually conical, occasionally obtuse 
papules (each pierced by a fine hair) that develop over the brow, about 
the eyebrows, over the cheeks, and the inframaxillary region. 

Etiology. — Puberty and uncleanliness have been assigned as causes 
of the disorder ; both conditions may in some patients be indirectly 
effective. In certain individuals the condition seems to follow a pro- 
longed course of arsenic. The disease is seen frequently in persons 
having peculiarly thick, coarse, usually dark-colored skins, and also 
possessing marked muscular vigor and unusual development of most of 
the other bodily tissues. In brief, the disorder seems to be due often 
to marked inherited predisposition in persons of vigorous constitution. 
The varieties of keratosis pilaris seen in cachectic hospital-patients, and 
in persons who have aggravated the disease by inducing a medicamentous 
rash upon the person, belong to a different category. Patients in the 
two classes last named may be so perfectly relieved that there is no 
predisposition to a return of the disorder, a relief not always to be 
secured by the others. 

Pathology. — Keratosis pilaris is produced by accumulation of the 
cells of the horny layer of the epidermis and sebaceous material about 
the orifices of the hair-follicles. In some cases the result is an irrita- 
tion which produces a mild grade of chronic inflammation of the peri- 
glandular tissue. Giovanni in twelve cases examined found atrophy 
of the hair-papillse. Entire absence of sebaceous glands in three-fifths 
of his cases, and very marked atrophy in the remainder, were noted 
also. Necrosis of the outer end of the arrectores pilorum was observed 
in a few instances. 

Diagnosis. — The disease should readily be recognized by the pecu- 
liarities of its seat, its course, and the nature of its symptoms. From 



444 HYPERTROPHIES. 

ichthyosis it can be distinguished by the limitation of its lesions to 
the orifice of the hair-follicle ; from the transitory condition known as 
" goose-flesh " by its persistence after the surface of the skin is thor- 
oughly warmed ; from papular eczema and the other lichenoid erup- 
tions by the relatively insignificant character of the lesions, their evi- 
dent follicular origin, and either the entire absence, or mild chronic 
type, of inflammatory symptoms. 

The disease is to be carefully differentiated from pityriasis rubra 
pilaris, in which the characteristic disorder of the scalp, the appearance 
of plaques of disease covered with fine pityriasic scales (often upon the 
tip of the nose and chin), exhibiting a peculiarly dark, smirched appear- 
ance, the affection of the nails, the characteristic papulae on the dorsal 
surfaces of the first and second phalanges of the fingers, and the evident 
admixture of the disease with symptoms of seborrheic type, suffice to 
determine its nature. 

Though the lesions of keratosis pilaris bear little resemblance to 
the papular syphilodermata, many male patients for years swallow 
medicaments for relief of a supposed syphilis the sole " symptom " of 
which is a keratosis pilaris. The papular syphilodermata are not per- 
sistent year after year, are not throughout symmetrical, and are not 
limited largely to the outer faces of the limbs, especially of the thighs. 
They are preceded by a history of infection, and invariably are accom- 
panied by some other manifestations of the disease. They are not 
limited to the orifices of the hair-follicles, and are not capped by the 
peculiar horny scaling tip of the papule of keratosis pilaris. 

Crocker describes a Lichen Pilaris which he considers distinct 
from keratosis pilaris, as in the former the follicular elevations are 
more pronounced and resemble spines, there is usually evidence of 
inflammation, and the eruption tends to occur in patches instead of 
being diffuse. 

Treatment. — For the subjects of this disorder in its typical forms 
it is not sufficient merely to order a bath. The bathing should be 
conducted systematically for years at a time. 

As soon as it can well be tolerated the patient should be urged to 
bathe the entire surface of the body every morning by the use of the 
sponge and cold fresh or salt water, following this with brisk fric- 
tion with a coarse towel or a flesh-brush. The habitual use of this 
cold bath continued daily for years, in persons who can tolerate it 
(and patients affected with keratosis pilaris are usually of this class), 
accomplishes results of the most satisfactory character, exerting, as 
it does, a profound influence on the nutrition and healthfulness of 
the skin. 

For immediate treatment of the most of these cases, however, the 
hot bath with soap is desirable. This bath may be repeated as often 
as required to remove the lesions, and be followed in the more urgent 
cases by inunction with lanolin-pomades, or the fats or oils. Salicylic 
acid, 1 to 10 per cent, in oils or ointments, is effective in removing 
temporarily the horny accumulations. In the congenital and severe 
types, such as those -described by Fox, cod-liver oil internally should 
be ordered. 



KERATOSIS. 445 

KERATOSIS SENILIS. 

The skin of the aged may become harsh, dry, and unusually corni- 
fied either diffusely or in certain definite regions, such as the hands, 
feet, or extremities ; this may be regarded as the simplest form of 
keratosis senilis. The skin of the entire body or of the region affected 
is then dark in color, dry to the touch, occasionally covered with fine, 
rather adherent scales, representing merely attached and cornified cells 
of the horny layer of epidermis, and notably unprovided with the natu- 
ral unguent of the skin. 

In a more advanced grade the skin undergoes changes closely allied 
to epithelioma ; often, indeed, these both furnish the first symptoms of 
epithelioma and coexist with its gravest destructive effects. The skin, 
more commonly of the face, the hands, or the forearms, less often of 
the feet, the legs, and the genital regions of the aged, is covered with 
thin, horny, often greasy-looking, pinhead- to nail-sized and larger, 
dark-yellowish plates or scales, between which the integument that has 
undergone the atrophic changes in the senile skin is visible. Pig- 
mented puncta and macules may also appear scattered irregularly over 
the surface, with rough, dirty-yellowish to dark-brownish granular 
accumulations upon the skin of certain regions, such as the clefts beside 
the alse of the nose, the temples, etc. The appearance is suggestive 
in some cases of a seborrhcea sicca of the face. In many patients 
exhibiting these features a fully developed papillomatous, superficial, 
or deep epithelioma may be present. In other patients one or more 
varieties of the senile wart may be visible, as described in the chapter 
on Verruca. 

Viewing the subject of senile keratosis in the light of the knowledge 
had upon the subject to-day, it must be admitted that the boundary-lines 
between it and epithelioma are not well established. Unquestionably 
the exaggerated lesions of the former affection are frequently the first 
stages of the latter disease, and in the treatment of the skin of the 
aged, conducted on the general principles already set forth, the physi- 
cian should never lose sight of possibly serious consequences in one or 
more regions of the skin affected. 

KERATOSIS FOLLICULARIS. 

(Psorospermosis, Psorospermose folliculaire vegetante, Ich- 
thyosis FOLLICULARIS, ACNE SEBACEE CORNEE, DARIER's 

Disease.) 

In 1889 Darier l and Thibault in France ; White in America ; and 
later, Wickham, 2 Neisser, and others, called attention to a cutaneous 
disorder not previously distinguished from other maladies. Between 
twenty and thirty instances have been recorded. In reporting a new case 
Bo wen 3 gives a brief summary of the clinical and pathological charac- 
teristics of the disease as described by other observers. 

1 Annal. de Derm, et de Syph., July, 1889. 

5 Contribution a 1' Etude des Psorospermoses Cutan^es. Paris, 1890. 

8 Jour. Cutan. and Gen.-Urin. Dis., June, 1896. 



446 HYPERTROPHIES. 

In the few cases reported the eruption displayed was practically 
generalized, and was exhibited in greatest abundance over the limbs, the 
front of the chest, the inguinal and genital regions, the scalp, the face, 
and the loins. The first lesions were firm, pinhead-sized papules, scarcely 
different in color from that of the surrounding integument, which later 
assumed a deeper hue, and, whether flattened or hemispherical, these 
papules were soon covered with a grayish or brownish crust, greasy to 
the touch and apparently prolonged into depressions beneath, much as 
the crust of seborrhoea sicca of the face is sunk within the orifices of 
the sebaceous follicles. The papules, as they increased in size and age, 
became darker in hue until eventually they were a deep brown and red, 
or even purple. A few exhibited scratch-marks and were covered with 
hemorrhagic crusts. 

Over the scalp the symptoms are practically those of the crusting 
forms of seborrhoea, save that there is no tendency to loss of hair. 
Over the face the parts chiefly involved are the temples, the inside of 
the concha of the ears, and the folds about the nose and lips. Here, 
as over the parts of the trunk named above, form dark, even blackish, 
strata of dirty oil-crusts, spontaneously shed. Beneath each crust, as 
indicated above, there is usually a conical spur let into an infundibular 
depression, the latter representing the patulous orifice of a pilo-seba- 
ceous gland. Over the backs of the hand and fingers the papules and 
crusts are less numerous, but the papules are closely set together and 
tend to coalesce. In the palms and soles are numerous almost imper- 
ceptible lesions of the same type. As the disease advances to what 
has been described as a second stage the papules coalesce, forming 
small tumors and papillomatous growths, which involve not only the 
follicles, but also the interfollicular tissues. Many of the follicles 
become the sites of superficial ulcers, while the whole of the vegetating 
mass is bathed in a more or less abundant, fluid, muco-purulent secre- 
tion. The subjects of the malady often emit an offensive odor. 

The disease progresses gradually until large portions of the body 
are covered. Occasionally exacerbation with rapid spreading of the 
lesions occurs ; but, as a rule, the course of the affection is slow and 
the general health of the patient does not seem to suffer except sec- 
ondarily from the presence of ulcerating and suppurating lesions of 
the skin. 

Etiology. — Little is known definitely regarding the etiology of 
keratosis follicularis. In the majority of cases recorded it began in 
childhood, and in several instances in early infancy. Of twenty cases 
collected, thirteen were in males and seven in females. 

The theory first advanced by Darier, and later elaborated by Wick- 
ham and others, that this variety of keratosis, and probably also 
Paget's disease, some superficial forms of epithelioma, and molluscum 
" contagiosum," were due to the presence of psorosperms or coccidia?, 
has been abandoned even by its propounders. As a result of further 
study by Bowen, Buzzi, Miethke, Boeck, Darier, and others, these 
bodies, which closely resemble certain psorosperms, have been demon- 
strated to be produced by cell-transformation. 

White's cases were in father and daughter, while Boeck had three 



KERATOSIS. 447 

cases in one family. It is possible that contagion or heredity may have 
an influence in the production of the malady. 

Pathology. — The disease seems to be primarily a kyperkeratosis 
involving the sebaceous follicles and the hair-follicles. The process is 
confined for the most part to the neck of the follicle, but in the later 
stages it extends to the interfollicular tissues. The mouths of the pilo- 
sebaceous ducts are dilated into funnel-shaped openings and packed 
with masses of horny cells produced by the hyperkeratosis. Boeck 
and a few other observers believe, however, that the process is not 
essentially follicular, but that it may begin outside the ducts. 

The rete is usually thickened and in the later stages of the disease 
the interpapillary processes are prolonged. Mitoses are numerous, 
and in the lower layers of the rete are found fissures or lacunae, the 
exact significance of which is not yet determined. In places the pres- 
sure of the horny masses may produce thinning and atrophy of the 
rete. About the borders of the lesions there is an abundant pigment- 
deposit in both the epidermis and in the corium. The only other 
change noted in the corium is a small amount of cellular infiltration. 
The glands of the skin are unaltered. 

The round bodies formerly supposed to be psorosperms are found in 
the deeper and middle layers of the rete, and at the base of the horny 
plug filling the follicle. According to Bowen, they are swollen cells 
containing a nucleus which stains deeply, and which is surrounded by 
a clear or hyaline ring of protoplasm, outside of which is a zone con- 
taining granules of keratohyalin, the whole being surrounded by a 
homogeneous, glistening membrane, which may possess a double 
contour. Various modifications of this type are found as a result of 
irregular keratinization of the cells. In the upper layers, in which 
the process of cornification is advancing, the keratohyalin gradually 
disappears; but it may do so irregularly, and, losing its granular 
appearance, may give rise to appearances closely simulating nuclei and 
nucleoli. In the upper layers also the outer membrane may contract 
or disappear, leaving an empty space. At the bottom of the horny 
mass in the follicle the stratum granulosum is frequently absent, and 
there are seen irregular, shrunken, homogeneous cells with nuclei which 
stain but feebly. These cells are the " grains " of Darier, and Bowen 
believes they are cells which have become cornified without passing 
through the keratohyalin stage. 

Diagnosis. — The disease is to be differentiated from moll u scum 
epitheliale, which is never so generalized, and which always exhibits 
an enucleable mass containing the so-called " molluscous bodies." 

■ The papular forms of acne are eruptive elements which contain 
centrally a true corneous mass ; in keratosis follicularis there is a 
softish comedo-like central mass. The acne-forms, further, are not 
generalized. The disease bears close resemblance to some forms of 
ichthyosis, but a careful study of the history, the character, and location 
of the lesions will usually make the diagnosis clear. 

Treatment. — So few cases of the disease have been observed that 
the treatment is still undetermined. While marked improvement may 
be obtained, no complete recovery has been reported, and with a lapse 



448 HYPERTROPHIES. 






in treatment the unfavorable condition of the patient quickly returns. 
The parts are to be well cleansed by shampooings, and then dusted 
with borated, salicylated, and absorbent powders. The French, acting 
upon the parasitic theory of the nature of the affection, vigorously 
employ parasiticides, salves containing pyrogallol or iodoform, and even 
resort to cauterizations with zinc chloride. 

KERATODERMIA PALMARIS ET PLANTARIS. 

(Symmetrical Keratodermia of the Extremities, Congenital 
Keratoma of the Palms and Soles, Ichthyosis Palmaris 
et Plantaris.) 

A symmetrical and well-marked thickening of the palmar and 
plantar epidermis occurs as a result of several effective causes to which 
special attention has been directed, in France by Besnier and Doyon ; 
in Germany by Unna ; and in the United States by one of the authors l 
of this treatise in a communication, in 1887, to the American Dermato- 
logical Association. 

Symptoms. — Four varieties have been identified : 

In the first variety there is symmetrical thickening of the palms 
and soles, strictly congenital, in cases hereditary, and accompanied or 
not by nsevi situated upon other regions of the body. The epidermis 
of the involved areas is greatly thickened and a delicate erythematous 
halo extends beyond the border of the keratosis. The latter condition 
occasionally sweeps beyond the palmar and plantar regions to the dorsum 
of the affected fingers, toes, hands, or feet. The nails, the teeth, and 
the hair are not involved. 

The second group includes the more common variety of symmetrical 
keratodermia of the extremities, erythematous in type and possibly 
associated with a central neurosis. Here the epidermal thickening is 
exaggerated over the points of special pressure, though occurring inde- 
pendently of such agency, a fact well illustrated in a case in which the 
thickening at times developed while the patient was for months 
reclining in a hospital-bed. The disorder is worse in winter. There 
are the usual hypersemic zone at the border-line of the keratosis, and a 
great distinctness of definition of the latter with perfectly sound skin 
between the islets of epidermis sclerosed at the points of pressure. 
There are usually a coincident hyperidrosis, and dislocation of and 
structural change in the nails. The keratinized sole or palm sheds its 
horny envelope either as a result of treatment or spontaneously ; and 
even in the most pronounced cases the disorder may disappear. 

In a third form there are foci in which the keratosis is declared in 
multiple isolated points over the palmar and plantar regions, always 
independently of pressure and contact, due to a central trophoneurosis. 
The remote cause in some cases is the long-continued ingestion of 
arsenic. In a subvariety the orifices of the sweat-pores are distended 
with corneous plugs, resembling comedones, with concentric lamellations. 

A fourth variety is a partial, entirely curable, and accidental kerato- 

1 " Observations on Three Cases of Symmetrical Hand and Foot Disease," Med. 
News, Oct. 8, 1887. 



IPLATE^VIII. 





Keratosis Punctata in a Man who had been taking 
Arsenic for a long-standing Psoriasis. 

(From a photograph.) 



PLATE IX 




Palmar Keratosis, due to Arsenic. 

(From a photograph.) 



ANGIOKERATOMA. 449 

dermia of the extremities that is not to be confounded with the callosities 
described in another chapter. This form occurs at any age under the 
influence of pressure to which the limbs are unaccustomed. 

The Diagnosis of all forms of keratosis of the palms and soles is 
to be made from eczema, chiefly by reason of the absence of well- 
marked inflammatory symptoms, of vesicles, and of eczematous patches 
in other regions of the body. Palmar and plantar syphilides are to be 
distinguished with great caution. These last may be asymmetrical, 
especially if of " late " type ; may exist where there is often a history 
of infection or signs of lues ; and may often ulcerate. They have also 
well-defined circinate borders ; and the lesions are more often multiple 
and isolated. 

Treatment. — Internal treatment is by the methods employed in 
psoriasiform affections. Brocq advises the internal administration of 
sodium arseniate in large doses ; but in this connection it should be 
remembered that cases are reported in which keratosis of the palms 
and soles has apparently been produced by a long course of arsenic. 
The local treatment is by prolonged maceration of the parts, followed 
by shampooings with green soap in substance or tincture, followed by 
salicylated pastes, plasters, or solutions of salicylic acid in collodion. 
Mercurial plasters and mercuric oleates may also be used Avith advantage. 
Potassium hydroxide in 10 to 20 per cent, strength has been applied as 
a lotion to stimulate the surface. Other formulae recommended are 
salicylic acid and calomel, 1 part of each to 20 parts of glycerole of 
starch ; and 1 part each of resorcin, tartaric acid, and salicylic acid, to 
20 or 30 parts of the salve-basis. 

ANGIOKERATOMA. 

(Keeatoangioma.) 

This disorder was first described in 1889 by Mibelli; 1 later, cases 
of a similar character though differing in many details have been re- 
ported by Thibierge, Crocker, Zeisler, Pringle, Joseph, Fordyce, Cottle, 
and others. The cases are rare and they apparently occur with wide 
divergence of type. 

Symptoms. — The lesions may be first recognized upon the hands, 
where they resemble ordinary perniones, and are seated on the dorsal 
aspect of the fingers, especially of individuals who are much exposed 
to low temperatures or who handle cold substances in the trades, as, 
for example, those who dress cold beef in winter. Both the palms and 
the soles may be invaded. We have had under observation a typical 
case in which the lesions existed exclusively on the scrotum. Other 
instances of angiokeratoma of the scrotum are on record by Fordyce 
and others. Here, as over other regions of the body involved, the 
lesions may be commingled pinhead-sized and larger, translucent, 
horny-capped, roundish warts, tumors, or nodules, dull purplish in 
color, leaden-hued, or even chocolate-tinted, interspersed with flat 
macules (split-pea-sized for the most part, having a dark central 
punctum), which are at first removable by pressure and which event- 

1 Giorn. Ital. delle Malattie Yeneree, e della Pelle, September, 1889. 
29 



450 HYPERTROPHIES. 

ually persist. These lesions are often mere cutaneous varices. The 
globoid nodules may be smooth and horny at the surface or be rough- 
ened and prickly ; they are never scaly. At times the varicosities of 
vessels are commingled with both spots and nodules, transitional forms 
occurring in some cases. The arrangement of the lesions is in general 
irregular and asymmetrical, though there may be grouping. 

Etiology. — The patients are commonly young, but a few cases have 
been reported in middle-aged subjects. There is usually a history of 
exposure of the affected parts to cold weather or to cold substances, as 
described above. Some of the sufferers from the disorder seem to have 
been subject to chilblains. 

Pathology. — The first morbid change is a blood-stasis which results 
in punctiform capillary varices in the upper vascular web of the corium. 
Superimposed on these varicosities lie thickened areas of the epidermis, 
constituting a keratomatous tumor. The epithelial ridges in the vicinity 
of these minute wart-like bodies are compressed and thinned by the 
ectasis of the vessels. There is moderate local acanthosis, the granular 
layer also being increased in thickness and the lower part of the stratum 
corneum showing increase in elei'din. At the moment of fullest evolu- 
tion the affected papillae are transformed into small cavernous angiomata, 
sometimes reaching upward to the epidermis, while thinned processes 
of the latter stretch downward toward the cutis. The sweat-pores are 
at times narrowed ; at others they seem to be normal. 

The Prognosis is favorable, as the lesions may be made to disappear 
under proper treatment. 

Treatment is by stimulating lotions and liniments, as in pernio, 
and, when required, by electrolytic destruction of the vascular warts. 



• 



KERATOSIS FOLLICULARIS CONTAGIOSA. 

(Acne Sebacee Coknee.) 

H. G. Brooke 1 described under this title a rare and apparently contagi- 
ous disorder occurring in children and occasionally in adults. Blackish 
macules were symmetrically developed into deeply pigmented papules 
over the neck, the shoulders, and the extensor faces of the arms. 
From these papules protruded blackish specks, which later resembled 
comedo-plugs and eventually developed as spike-like filaments. The 
skin, however, was dry, never greasy, of a dirty shade of color ; and the 
thorny excrescences were firmly attached to the tissue beneath. We 
have had under observation a young woman who exhibited precisely the 
same features on the extensor surfaces of the arms, forearms, thighs, and 
legs. Unna divides the pathological symptoms into those due to reten- 
tion and those due to the formation of horny plugs at the sites of the 
follicles. The lesions are distinguishable from those of acne and comedo 
by the absence of sebaceous cells and by their collar of horny lamellse 
at the base. The spokes are produced by the energy of the hyperkera- 
tosic process, which pushes the horny plug outside of and beyond the 
follicle, its upper segment only being concerned in the process. The 
disease is essentially a hyperplasia of the epithelial cells, the first evi- 

1 Internat. Atlas of Rare Skin-diseases, 1892, xxii. 



POROKERATOSIS. 451 

dence of the operation of the external cause being apparent in the 
stratum granulosum, the chief result being declared in the common 
excretory duct of the pilo-sebaceous conduit. The disease was readily 
relieved by applications of lard saponified with potassium hydroxide. 

HYPERKERATOSIS STRIATA ET FOLLICULARIS. 

H. v. Hebra l reports under this title the case of a young woman 
with isolated epidermal elevations, having a reddish margin, of both 
superciliary arches, over the bridge of the nose, the upper lip, the 
throat, shoulders, and arms. The lesions w r ere flat or elevated, iso- 
lated or confluent nodules, constituted of heaped-up epidermis, which 
could be removed without disturbing the papillary layer of the corium. 
Many were bean-sized, grayish-green elevations, conspicuous over the 
elbows, with underspreading epidermic cones buried in corresponding 
depressions beneath, which often bled freely when the cuticular mass 
was removed. Contrasting with these lesions were striated elevations 
of epidermis extending either at an angle or along the longitudinal 
axis of the limb. The disorder was relieved by warm-water and soap 
baths, followed by resorcin-vapor and salicylated plaster. 

PARAKERATOSIS SCUTULARIS. 

This name has been given by Unna 2 to a rare condition occurring 
in a vigorous man (first on the scalp), in which thick, somewhat greasy 
crusts enveloped bundles of hairs, the separate filaments having yel- 
lowish and horny cuffs that were fused with the crust. Whitish scales 
and horny cylinders w 7 ith a perpendicular projection were visible over 
several portions of the face. Upon parts of the trunk were brownish 
spots, coin- to palm-sized, exhibiting horny cones which projected from 
the follicular orifices. The cones were covered with horizontally 
placed scales. Dark-reddish, moist, and shining surfaces were ex- 
posed on their removal. Closely examined, the horny cones after re- 
moval displayed several hairs which projected, one above another, 
from each cone, having been extruded from their follicles at different 
times. The author believes the disease to be allied to Devergie's 
pityriasis pilaris. 

POROKERATOSIS (Mibelli). 
(Hyperkeratosis Excentrica (Kespighi)). 

This rare form of hyperkeratosis, described by Mibelli, 3 Respighi, 4 
Hutchins, 5 Gilchrist, 6 and others, begins as a minute, elevated, wart-like 
papule which gradually enlarges peripherally to form a small plaque 

1 Internat. Atlas of Rare Skin-diseases, 1891, v. 

2 Ibid., 1890, i. 

3 Ibid., 1893, vol. ix.; Monatshft. f. prakt. Derm., 1897, p. 345, etc. 

4 Giorn. Ital. delle Malattie Veneree, e della Pelle, 1893, p. 356. 

5 Jour. Cutan.and Gen.-Urin. Dis., 1896, p. 373. 

6 Johns Hopkins Hosp. Bull., viii. ; Jour. Cutan. and Gen.-Urin. Dis., 1899, p. 149 
(with bibliography to date, etc.). 



452 HYPERTROPHIES. 

with a depressed centre and a characteristic, narrow, slightly elevated 
border, in the form of a " dike " or " raised seam," along the crest of 
which is a depressed black line or series of black dots. This crest 
may be continuous or be broken at intervals, or may be surmounted here 
and there by small conical elevations. This peculiar ridge inclosing a 
depressed centre can be made out in lesions that have attained a diam- 
eter of two millimetres or more. Many of the lesions do not reach a 
size greater than one centimetre in diameter, but some become much 
larger and may cover the greater portion of an extremity. The smaller 
plaques are circular, but the larger ones may have an irregular and 
sinuous outline. 

Within the border the surface in small lesions is depressed but 
callous, while in the larger areas it usually is thinned and atrophic, 
but may be of normal thickness, with sometimes a few small round 
horny elevations superimposed. Absence of hair and of perspiration 
is noted in some of the areas, while in others both are present. There 
are no evidences of inflammation, and as a rule no subjective sensa- 
tions. Some of the lesions may fail to attain typical development and 
exhibit a border but slightly elevated in which the furrow is the most 
conspicuous feature ; or they may appear as flat horny or scaly disks. 

The disease began in most instances between the second and eighth 
year of life, but in one of Respighi's cases it first appeared at the age 
of twenty-eight years. The lesions develop slowly, and may be limited 
for years to one region. The disks may be single, but usually are mul- 
tiple and may be very numerous. They occur in any region of the 
body, including the mucous surfaces. We have seen the disease in 
typical development on the glans penis. 

The causes of the disease are not known. Bacteriological investi- 
gations have given negative results. Gilchrist's eleven cases occurred 
in four generations of one family. Two other families are reported 
in which there were two or more cases of the disease. 

Pathologically the disease is a hyperkeratosis beginning in the 
deeper parts of the horny layer or in the upper portion of the rete, 
and involving chiefly the sweat-ducts, but also the hair-follicles and 
sebaceous glands. No inflammatory changes are found. 

Treatment of the smaller lesions with the electrolytic needle has 
been successful. Those which are larger may be excised. Recurrence 
after curetting was reported in one of Gilchrist's cases. 

MOLLUSCUM EPITHELIALE. 

(Lat. molluscus, soft.) 
(MOLLUSCUM VeKRUCOSUM, MOLLUSCUM SEBACEUM, EPITHELIOMA 

Contagiosum, Molluscum Contagiosum (Bateman), Acn£ 
vakioliforme (Bazin).) 

Molluscum epitheliale, a disease first recognized in 1817 by Bate- 
man, under the title Molluscum Contagiosum, is to be distinguished 
from another, known for a long time as molluscum fibrosum. The two 
disorders are distinct, and are no longer to be confounded by a simi- 
larity in name. 



MOLLUSCUM EPITHELIALE. 



453 



Symptoms. — Typical epithelial mollusca are firm, roundish bodies, 
averaging in size the dimensions of a pea, and in color varying from 
a waxy whitish hue, nearly that of the integument, to the dark-red tint 
of injected masses. They are either imbedded in the skin or project 
from it in smooth, firm, semiglobular, sessile or pedunculated tubercles. 
Usually a dark-colored aperture can be detected at the apex or side of 
the lesion, from which, on pressure, milky and curd-like, semifluid 
contents can be made to exude. Occasionally, inspissated or even horn- 
like masses project from these orifices, as though forced out by a vis-a- 
tergo. The disease is rare, and the lesions are usually single and iso- 
lated, though hundreds may appear upon the person of one individual. 

Fig. 51. 




Molluscum epitheliale. (After Allen.) 



They consist of semifluid collections derived from that portion of the 
rete which lines the sebaceous glands or penetrates between the papillae 
of the derma; or they are actual transformations of the glands into 
cornified amorphous deposits, surrounded by thickened parietes. They 

j may be removed by surgical procedures ; or be shed spontaneously ; or 
inflame, and result in circumscribed abscess; or terminate by ulcera- 
tion. More often they are insidious and slow of development, and may 
persist for years without producing annoyance or subjective sensation. 
They occur on the face, the side of the neck (Fig. 51), and the nucha; 

' on the penis and scrotum of men, and the breasts and labia of women; 
on the trunk ; on the flexor surfaces of the extremities, and the dorsal 
surfaces of the hands and feet. Thev are most common in children. 



454 



HYPERTROPHIES. 



In consequence of the depression of the centre of the little tumors 
(which Hutchinson has happily likened to small pearl buttons) they 
may suggest the lesions of variola, hence they were described by Bazin 
under the term Varioliform acne. This title, however, is by most 
writers employed to designate a totally different affection, a variety of 
acne vulgaris, to which a chapter is devoted in this work. 

Hebra, Virchow, and Nicolaysen have reported mollusca as large 
as an orange or a small cocoanut. Microscopical examination of these 
gigantic lesions demonstrated their identity with the smaller tumors. 
Similar bodies of less size have been found interspersed among 
epitheliomata. 

Etiology. — In England where the disease was first recognized, it 
is more frequent than on the continent of Europe. The contagiousness 
of molluscum is experimentally established, though the lesions are 
feeble in propagation by contact. Retzius, Vidal, Peterson, and "Wig- 
glesworth succeeded in producing the disease by inoculation of the 
contents of molluscous tumors. The proofs of contagion apart from 
experimental inoculation rest chiefly upon the circumstance of lesions 
being simultaneously or successively observed on the breast of a mother 
and the face of her nursling, and upon the successive development 
of mollusca in several members of one family. An interesting relation 
would seem to subsist between mollusca and verrucae, or ordinary warts, 
which are supposed to be feebly contagious. 

Stelwagon l has accumulated and classified reports of cases and of 
inoculations which seem to leave little doubt as to the parasitic nature 
of the disease. Eczema, sweating (Turkish baths), pruritus, and 
maceration of the skin predispose to the occurrence of mollusca ; but 
there are insufficient grounds for assuming that in adults they are 
associated with venereal disease. They are not rarely seen in large 
numbers upon the scrotum of youths who have never exercised the 
sexual function. 

Pathology. — Sections through the centre of a lesion of molluscum 
epitheliale show that it is formed by a number of diverging flask- 
shaped lobules, the small end of each lobule 
opening into a common central cavity. The 
lobules are separated from each other by a 
thin fibrous partition, which may occasion- 
ally be demonstrated to be the remains of a 
papilla. The entire mass or group of lobules 
is surrounded, except at the surface-open- 
ing, by a fibrous capsule, thus giving the 
entire structure an appearance very similar 
to that of a sebaceous gland. The belief, 
formerly held, that the process originated in 
the sebaceous glands, is erroneous. Minute 
examination fails to find any trace of a seba- 
ceous gland in these formations. The process begins as a proliferation 
of epithelial cells in the lower layers of the rete. The growth is con- 
fined to the rete, from which the flask-shaped processes are pushed out, 

1 Jour. Cutan. and Gen.-Urin. Dis., February, 1895. 



Fig. 52. 




Molluscous corpuscles. 
(After Kaposi.) 



MOLLUSCUM EPITHELIALE. 455 

causing a flattening and more or less complete disappearance of the 
underlying papillae. 

Each lobule is lined with a layer of palisade-cells continuous with 
the same layer in the healthy rete adjoining the growth, and is filled 
with round and cuboidal nucleated epithelium undergoing peculiar 
changes. The first two or three rows of cells are usually normal, 
but above them the changes become gradually more marked. The 
exact nature, sequence, and signification of these changes are in 
dispute, but it would seem to be fairly well established that the outer 
part of the cell shows early in the process abundant granules of kerato- 
hyalin, and soon undergoes a cornification forming a clear ring or 
" capsule " for the cell. Within, the changes are similar to those seen 
in amyloid or colloid degeneration. Authors describe a granular condi- 
tion surrounding the nucleus which is usually at one end of the cell, 
while the remainder of the cell-protoplasm shows vacuoles or groups 
of small, irregularly shaped hyalin bodies, uniting to form an oval 
mass which gradually encroaches upon and distends the cell. This 
oval homogeneous corpuscle surrounded by a horny capsule forms the 
so-called "molluscum body." These bodies accumulate at the mouths 
of the lobules and in the small common cavity into which the lobules 
all open, and may be pressed out upon the surface of the skin in a yel- 
lowish or whitish semifluid or waxy mass. 

The more minute changes in the cells and the methods of recogniz- 
ing them are given in detail by Unna and others. The theory that the 
disease is caused by psorosperms has been abandoned. 

Diagnosis. — Mollusca resemble the lesions of variola more than any 
other cutaneous phenomena. They are, however, readily distinguished 
from the latter by their chronicity, their semifluid contents, the absence 
of febrile symptoms, and the career of variolous pustules. From 
warts they are also differentiated by their contents, hemispherical shape, 
and the dark punctum almost invariably present on one part or another 
of the lesion. 

Molluscum epitheliale in no way suggests molluscum fibrosum, with 
which it has been confounded only in consequence of the similarity in 
name. The tumors of molluscum fibrosum are solid new-growths, 
usually occurring in great numbers upon the trunk of individuals of 
adult years. They may attain enormous dimensions, the masses 
reaching several pounds in weight ; and though in cases they degen- 
erate by ulceration, they never enclose the curdy contents of molluscum 
epitheliale. 

Papillary warts are to be distinguished from mollusca, though with- 
out question lesions are occasionally seen of a type intermediate between 
the two forms. Warts are to be recognized by their general papilli- 
form character, and by their evident relation to the papillary layer of 
the corium overlaid by a thickened stratum corneum. 

Physicians are occasionally consulted by patients who have discov- 
ered mollusca upon the genitals, and who suppose these lesions to be 
of venereal origin. An error in this respect can scarcely be committed 
by the expert. Neither the solid papule of the initial lesion of syphilis 
when observed on the skin of the penis, nor the pustule and resulting 



456 HYPERTROPHIES. 

ulcer of the chancroid, ever exhibit the waxy look of genital mollusca 
with their depressed puncta. In such cases the inguinal glands should 
always be carefully examined, remembering, however, that a forcibly 
squeezed and cauterized molluscum may be accompanied by sym- 
pathetic adenopathy. 

Treatment. — Molluscous tumors may be removed by ligature, 
scissors, knife, curette, or a needle in contact with the negative pole 
of a galvanic battery, their contents having previously been expressed. 
In order to diminish the pain of the trifling operation the affected sur- 
face may first be chilled or frozen with an ethyl-chloride or ether spray. 
Bleeding is easily arrested with a pledget of lint. Occasionally after 
removal the point of a crayon of silver nitrate may be introduced, 
either to check hemorrhage or to insure destruction of the cyst. Ac- 
cording to Hebra, the return of the lesion, when this occurs, may be 
expected at situations previously not implicated. 

When the lesions are small and numerous they may be made to 
exfoliate by the local application of green soap. Removal of the larger 
lesions may be followed by minute cicatrices. 

Prognosis. — The disease can always be terminated by removal of 
the tumors, the process to be repeated in case of recurrence. 

CALLOSITAS. 

(Lat. callus, hard flesh.) 

(Keratoma, Tyloma, Tylosis.) 

Callosities are superficial, circumscribed, dirty-white, yellowish- white 
or darker, flattened, thickened, and horny patches of epidermis, dense 
in structure and usually insensitive. Section of a single plaque shows 
it to be largest at the centre and least at the periphery. Callosities 
vary in size from that of a finger-nail to that of a section of a hen's 
egg, being at times larger ; they occur chiefly upon parts of the integu- 
ment subjected to long-continued intermittent pressure, as the hands 
and feet ; also upon parts stretched over osseous prominences, as those 
over the ischia. They may be complicated by hyperemia, fissure, acute 
inflammation, or erysipelas ; and readily serve as foci of cutaneous dis- 
ease (eczema, psoriasis, etc.). They are commonly encountered among 
mechanics, carpenters, shoemakers, etc. ; among persons wearing ill- 
fitting shoes (heel, or ball of foot, or big toes), stockings, or surgical 
apparatus ; among workers in metals, acids, or heated substances ; and 
among musicians (harpers, banjo-players, etc.). They are produced by 
such external causes as pressure, friction, chemical agents, and heat. 
They can readily be distinguished from eczematous, psoriasic, and ich- 
thyotic patches, being always limited to the sites of external contact. 

Callosities are so characteristic of the several professions and trades 
that by their locality alone they point in many cases to the occupation 
of the individual who exhibits them. Often they are, in these cases, 
essential to the prosecution of such work ; and their removal would 
only expose a tender epidermis to the operation of an injurious pressure 
or friction. 



CLAVUS. 457 

The pathological features of callosities are: marked hypertrophy 
and compaction of the stratum corneum and thickening of the stratum 
granulosum, the rete mucosum on the contrary being thinned by the 
pressure. The papillae are often flattened from the same cause. The 
corium may exhibit signs of inflammation when the callosity has been 
converted into a source of irritation. 

Callosities require treatment only when they are sources of pain or 
of discomfort. They may be removed — surgically, by the knife ; chem- 
ically, by the destructive action of acids or alkalies ; rationally, by dis- 
use of the part to an extent sufficient to interfere with the operation 
of the cause. When painful they may be poulticed. A nightly soak- 
ing of the callus with warm oil, kept in contact with the thickened 
epidermis during the hours of sleep by a compress of flannel saturated 
with the same substance, will in the end soften the induration. 

Callositas of the Hands, with Unusual Complications 
(reported by Morison, 1 of Baltimore), is illustrated by the case of a 
negro who was a stoker. In this instance the combined effects of heat 
and friction resulted in ulcerations beneath the callosities that event- 
ually produced necrosis and loss of some of the phalanges. This 
patient recovered as soon as the hands were properly protected, a fact 
that seems to justify the assignment of this and similar cases to a class 
apart from those which follow. 

CLAVUS. 

(Lat. clavus, a nail.) 

(Corn. Fr., Cor, CEil de Perdrix ; Ger. y Huhnerauge.) 

Corns are hypertrophies of the horny layer of the epidermis, with 
the peculiarity of presenting inferiorly a coniform prolongation, which, 
being pressed from without inward upon the sensitive papillse of the 
corium, excites pain in various degrees. Corns vary in size from that 
of a pea to that of a large chestnut, and are dense and callous when 
occurring upon those prominent parts of the foot on which the boot, 
shoe, or gaiter exercises its greatest pressure. When occurring upon 
the lateral face of a toe in apposition with another the corn originates 
usually from pressure through the medium of the neighboring toes. It 
is then softer from exposure to heat and moisture. Corns are often 
weather-sensitive, being unusually painful before, during, or after the 
occurrence of storms, and should not be confounded with gouty or 
rheumatic deposits below the skin. 

Histology. — Corns are composed of superimposed, and often con- 
centrically arranged, layers of epithelium, between which are found at 
times minute hemorrhagic extravasations. They are occasionally seen 
upon the palms of the hands. At the periphery of the corn the corium 
is unchanged, but at the point where its central cone is pressed into the 
deeper structures the papillae are either atrophied or absent. A corn 

1 Jour. Cutan. and Ven. Dis., Jan., 1886. 



458 HYPEHTROPHim 

at the periphery exhibits, according to Unna, a thickening of the 
prickle- and granular layers. There is a central horny layer, the outer- 
most stratum of which gives evidence of "welding." But the core 
itself, which is composed of compressed masses of the horny layer con- 
ically pointed below, exhibits a flattened ridge-net and papillary body. 
Often the sweat-pores are preserved, and may be traced running dilated 
and with many windings through the epithelium deeply into the core. 
The granular layer here disappears, and the general flattening is so 
great that the margin between the horny cells and the flattened prickle- 
layer is lost. 

Treatment. — Corns, when rationally treated by disuse of the feet, 
or by the adjustment of properly fitted coverings for the same, will 
usually fall spontaneously. They may be softened by prolonged mac- 
eration in water, by poultices, or, best of all, by oil, as in the treatment 
of callosities. Erasion and excision may be practised, if demanded by 
an exigency. Where the sufferer must necessarily continue the use of 
the foot the simplest and best treatment is as follows: The part is 
thoroughly macerated for half an hour with water as hot as can be 
tolerated. Then the projecting callous portion of the corn is gently 
removed by cutting or scraping until, as nearly as may be, the surface 
is level with the plane of the adjacent skin. The part is then dried, 
and the entire surface, both of the seat of the corn and the adjacent 
integument, is completely covered with many narrow, short, and nicely 
adjusted strips of rubber-plaster. Burgundy pitch melted and painted 
over the part may be applied as a substitute for the plaster. When 
the trifling operation and dressing are complete the patient should 
bear firm pressure over the corn without flinching, and walk with 
comfort. The plaster remains until it separates spontaneously, which 
is usually in the course of a few days. The corn is then macerated at 
■ night with an oil-poultice, as described above, and the dressing after- 
ward reapplied, usually the second time by the patient. Persistence 
in this course is followed by complete relief if the coverings of the 
feet be properly fitted. Caustics are usually unnecessary when there 
is no ulceration of the hard corn, and are in this situation frequent 
sources of great distress. They are chiefly valuable in the treatment 
of the soft variety, but they should always be applied with a skilled 
hand. 

For this purpose acetic acid or the silver nitrate crayon may be 
employed. The proprietary " corn-salves " sold in the shops commonly 
contain the ointment of mercuric nitrate, which also is a useful applica- 
tion to the soft variety of corn. The latter should be protected by the 
interposition of absorbent cotton or wool from contact with adjacent 
toes. 

As a rule, the ringed corn-plasters sold in the shops are inferior to 
the dressing with the rubber or salicylated plaster, made to cover the 
entire corn. 



CORNU CUTANEUM. 



459 



Fig. 54. 



CORNU CUTANEUM. 

(Lat. eornu, a horn.) 

(Horn. Fr., Corne de la Peau; Ger., Hauthorx.) 

Cylindrical, conical, straight or twisted, angular and otherwise 
irregularly shaped and sized corneous eminences, single or multiple, 
occasionally project from the scalp, forehead, nose, lips, ears, penis, 
or extremities. The sites of preference are in the following order, 
the scalp, forehead, temples, nose, lower extremities, male genitals, 
and trunk. Horns are 
named from their resemb- 
lance to the similar appen- 
dages in horned cattle, but 
they widely differ from cat- 
tle-horns, which are always 
implanted upon osseous 
tissue. Human horns are 
formed of dense and massed 
columns of epithelia, often 
resting upon prolonged pap- 
illa?. Occasionally, on sec- 
tion, they exhibit the con- 
centric arrangement of the 
epithelia seen in corns, but, 
unlike the latter, have re- 
entrant basal depressions into 
which the papillae below pene- 

Fig. 53. 





Varieties of cutaneous horns. 

trate. At times they are implanted in a dilated follicle, in which case 
| the glandular elements participate in their formation. At times, also, 

they represent a corneous transformation of the epithelia which con- 
< stitute warts. They are seen in all colors, but are often between a 

yellowish brown and a brownish black, with fissured or wrinkled 

or longitudinally grooved exterior, like rough bark (Fig. 53). They 



460 HYPERTROPHIES. 






may be painless, or, like other keratoses, become the seat of inflamma- 
tion in various grades. They may be short or several inches in length 
(Fig. 54). They may be shed spontaneously never to return, or may 
shortly reappear. They occasionally develop into epitheliomata. 

Brinton l has exhibited an anteriorly curved horn one and seven- 
eighths inches long and three-eighths of an inch in circumference, re- 
moved by him from the glans penis of an elderly patient. Fourteen 
cases are on record of a similar growth in this situation. In the 
horn growing from the lower lip of an elderly man exhibited in 
1886, at our clinic, the growth w T as longitudinally furrowed, and also 
at somewhat regular intervals transversely seamed, presenting thus the 
appearance of the joints of the sugar-cane. 

The Etiology is without question that of the senile wart for most 
cases ; though, as with epithelioma, horns occur in infancy. They have 
been recognized as starting from a sebaceous cyst. 

Pathology. — Pathologically these hypertrophies are first developed 
either within a closed atheromatous cyst or from remarkably elon- 
gated papillae of the corium. They are made up of cornified and hy- 
pertrophied epidermal cells. According to Unna, they are all papil- 
lary and medullated keratomata growing on a circumscribed warty 
base. The first stage of their development is characterized by a sim- 
ultaneous acanthosis and hyperkeratosis, dense epithelial taps reaching 
toward the corium. In the second stage of horn-formation the kera- 
tosis advances and the acanthosis diminishes. Sets of horny wedges 
sink downward into the epithelial taps and ridges, fill the spaces be- 
tween the papillse, and are capped above by a horny cupola. 

Lebert shows that horns develop into epitheliomata in about 12 
per cent, of cases. As horns are really metamorphoses of epidermal 
cells similar in many features to warts, it is not surprising that the two 
often undergo the change from benign to malignant epithelial growths. 
In a few cases horns have developed to an appreciable degree on epi- 
theliomata; but under the microscope this horny metamorphosis on a 
smaller scale may be recognized in a large number of epitheliomata sit- 
uated on the back of the hands of elderly men who have been farm- 
laborers, sewer-builders, or workers in contact with earth. 

Treatment. — Horns may be removed by extirpation, after which 
the surface upon which they were implanted should completely be 
cauterized. 

Prognosis. — In formulating a prognosis the possibility of an epi- 
theliomatous result should not be forgotten. 

VERRUCA. 

(Lat. verruca, an excrescence.) 

(Wart. Fr., Verrue ; Ger., Warze.) 

Warts are cutaneous excrescences ; congenital or developing after 
birth ; sessile or pedunculated ; pointed or flat ; smooth, rugous, or 
having a cauliflower appearance ; pigmented in various shades or of 

1 Jour. Cutan. and Gen.-Urin. Dis., 1887, p. 272. 



PLATE X. 










te& 





Congenital Warts. 

(From a photograph ot one of the author's patients.) 



VERRUCA. 461 

the natural color of the skin ; soft, dense, or even corneous to the 
touch. They may develop slowly or rapidly, and may persist for years 
or disappear without apparent cause. They may be single or multiple, 
and they occur upon the hands, feet, face, scalp, neck, genitals, and 
other parts of the body. They are usually discrete, but may be con- 
fluent and form palm-sized and larger elevated plaques. Fox, of New 
York, has reported a case in which warts occurred in the lines tattooed 
on the skin of a young man. 

The several names given to the various forms of warts have chiefly 
a descriptive value. 

Verruca Acuminata (Condyloma ; Moist Venereal Wart. Ger., 
Spitzen Warzen) is a filiform, papilliform, or cock's-comb-like vegeta- 
tion. They are single or multiple ; at times hundreds coexist upon the 
genitalia and neighboring regions. In size they vary from that of a 
pin's point to that of a hen's egg, and may be larger. They are usu- 
ally moist and secreting, being frequently covered with a puriform 
mucus of exceedingly nauseating odor. Upon the genitals they are 
encountered upon the glans, around the frenum, and over the prepuce 
of men ; and in women about the clitoris, labia, ostium vaginae, and 
anus. They are usually of a bright-red color in these situations. When 
occurring upon the integument they are firmer, drier, and exhibit a ten- 
dency to luxuriant growth. In this form they may be recognized about 
the axillary regions, the umbilicus, the interdigital spaces of the feet, 
and even the face. They may cover the side of the chin. 

The summit of these warts may be tufted, acuminate, or flattish ; 
on the surface of the skin, unconnected with mucous membrane, they 
may have the color of the unaltered integument. They are often 
minute and numerous as well as multiple and large ; or they may be 
single throughout, though, as a rule, they multiply when untreated. 
Their largest maximum development is observed in negroes, in whose 
persons they may attain unusual proportions. There was lately exhib- 
ited at our clinic a male negro with a compound venereal wart of the 
penis that was of the size of an orange. 

These warts are almost always the result of exposure of the sexual 
parts to venereal secretions (blennorrhagic, syphilitic, leucorrhceal, etc.), 
and, though observed in virgins, are decidedly rare in individuals of 
both sexes of that class. In pregnancy they often attain a large size 
and rapid development, but, as a rule, disappear when parturition is 
completed. They are contagious and furnish auto-inoculable secretions. 
Cocci and bacilli have been recognized in several varieties, thus explain- 
ing many otherwise obscure histories. 

Verruca Acquisita is a term used to designate lesions developed 
after birth. 

Verruca Congenita. — Congenital warts are usually first noticed 
several months after birth. They may be single or be multiple, 
usually the latter, in which case they are arranged along the lines of 
distribution of the nervous trunks, the disposition of the lesions often 
suggesting the arrangement displayed in zoster of the trunk or other 
region. They are, as a rale, roundish, slightly pigmented, and scarcely 
larger than split pease. At times they acquire unusual dimensions. 



462 HYPERTROPHIES. 

The neck and shoulders may be well covered with lesions of this class 
in asymmetrical groups, the largest wart having the size of the section 
of an egg. 

Verruca Filiformis. — This variety of wart differs somewhat from 
the others, not only pathologically, as is noted below, but also in its 
clinical features. These warts are pointed growths, slender, thread- 
like, often pedunculated, usually covered with a smooth and apparently 
unaltered epidermis ; they occur upon the face, neck, eyelids, chest, 
and ears. Kaposi concludes that they are minute fibromata. 1 

Verruca Dorsi Manus et Pedis (Unna) is a nsevus with 
lesions symmetrically grouped upon the dorsal surfaces of the meta- 
carpi of the thumb and index finger. The lesions are flat, round, or 
polygonal, two to six millimetres in diameter, externally presenting a 
punctate appearance, occurring in middle or later life, and exhibiting 
no tendency to spontaneous change. Pathologically they disclose a dis- 
tinctive thickening of the prickle-layer from the periphery to the 
centre. They lack many of the characteristic microscopical features of 
the ordinary seborrheic wart. 

Verruca Glabra is distinguished by its smooth surface. 

Verruca Necrogenica is a tuberculous wart, occurring on the 
hands of person3 who have been in contact with tubercle-bacilli, chiefly 
as a result of handling the bodies of the dead. For details, the chap- 
ter on Tuberculosis of the Skin should be consulted. 

Verruca Plana describes a not uncommon variety of wart which 
is flat, smooth, and but slightly elevated. The plane warts may be 
single, but are commonly multiple, and they usually vary in size from 
that of a pinhead to that of a small split-pea, but may be much larger. 
They are often grouped, and may have a polygonal outline, closely 
simulating the papules of lichen planus. In young people these plane 
Avarts are usually small, multiple, often grouped; have the color of the 
normal skin or are slightly yellowish or whitish ; and are seen most 
frequently on the forehead, on other parts of the face, and on the backs 
of the hands. In older people this form of wart shows less tendency to 
grouping than in the young, is often pigmented, and may be associated 
with or form the beginning of superficial epithelial changes. 

Verruca Senilis vel Plana (Keratosis Pigmentosa). — These 
warts are bean- to coin-sized, smooth, softish growths developed upon 
the face, trunk, and extremities of persons of advanced years. They 
are flat, usually pigmented, and have a granular aspect. They are 
readily separable by the finger-nail, and are then found to rest upon 
a reddish granular base. As the result of external injury (caustics, 
traumatism) they may become the starting-point of an epithelioma. 

Verruca Vulgaris is the form most frequently seen upon the 
fingers and hands, as pinhead- to pea-sized, usually discolored, papilli- 
form excrescences. 

Etiology. — Most warts are nests of micro-organisms of different 
varieties. The precise cause, however, is unknown ; but in early child- 
hood, a period in which warts are most frequently encountered, it is 
1 See Taylor's observations as epitomized in the chapter on Fibroma. 



VERRUCA. 463 

reasonable to conclude that they result from external contacts. It is 
when the child begins to handle everything within reach that they 
usually first appear, and then about the hands. Acuminate or condy- 
lomatous warts chiefly occur in parts moistened with a blennorrhagic 
secretion, but unquestionably they may originate from contact with 
leucorrhoeal or pathological, non-venereal discharges from the female 
genitals. Senile warts are more probably due to obscure changes in 
the nutrition of the integument. The etiological importance of the 
cocci and bacilli which many of them furnish cannot be determined 
at this time. 

Pathology. — The process begins with downward and upward growth 
of the rete-cells, resembling in this respect benign epithelioma. The 
granular layer is remarkably thickened, while the greatly hypertrophied 
horny layer is less compact than normal owing to imperfect keratini- 
zation of the cells, in many of which the nucleus is still apparent. 
The descending rete-processes are usually pointed and turn toward 
a common centre, producing thus a shallow cup-shaped depression in 
the cutis. 

The papilla? beneath the wart are flattened, many being obliterated, 
except a few at the centre of the base. These hypertrophy, become 
elongated, and with their dilated vessels form a vascular " core " for 
the verruca. In the pointed forms the connective-tissue and vascular 
elements are marked, while the horny layer is but slightly hyper- 
trophied. In verruca plana the chief change is in the rete, the horny 
layer being but little thicker than normal. 

Diagnosis. — It is a matter of importance to recognize the fact that 
I many epitheliomas begin as warts ; therefore the verruca of those ad- 
. vanced in years should always be examined and treated with a view 
i to this fact. A tendency, especially in the aged, for the lesion to break 
(down into an ulcer should arouse suspicion. Warts on the face and 
the backs of the hands of the aged are often of this class. 

Another class of warts are tuberculous in character, and, whether 
occurring in the young or the aged, are the result of infection with 
tubercle-bacilli, a generalized tuberculosis at times originating in these 
lesions (vide Tuberculosis Verrucosa). 

Great care must be had to distinguish the moist variety from syphi- 
litic condylomata. In the latter there is usually a history of conta- 
gion with other syphilodermata upon' the surface, such as mucous 
patches, palmar lesions, or papules of the face. Fibroma, or mollus- 
cum fibrosum, generally occurs in tumors of greater number, firmer 
consistence, and larger size. The tumor of molluscum epitheliale 
greatly resembles a wart, but the waxy-whitish appearance of the 
'lesion and its dark punctum at one plane or another sufficiently dis- 
tinguish it. In exceptional cases verruca plana may in shape and 
grouping closely simulate lichen planus, but the location and history, 
together with the absence of the typical color, the varnished appear- 
;ance, and of the itching, characteristic of lichen planus, will make the 
diagnosis clear. 

Treatment. — Warts may be removed by excision, erasion, or caus- 
tics (silver nitrate, alkalies, acids, ferric chloride, corrosive sublimate, 



464 



HYPERTR OPHIES. 



etc.). The larger growths upon the genitalia that are often highly 
vascular may demand the prior application of a ligature when they are 
pedunculated. Even the slender filiform warts will be found to contain 
a small vessel in each pedicle that requires cauterization after excision. 



Fig. 55. 




Vertical section of the summit of a pointed wart : a, papilla containing vascular loop ; c, stratum 
corneum ; d, hypertrophied rete. (After Kaposi.) 

When the warts cannot more readily be removed by the knife or by 
curved scissors the Paquelin cautery may be used. The blackened 
eschar which is left prevents hemorrhage, serves as the best subsequent 
dressing, and is less likely to be followed by a return of the growth. 
In some eases it is a useful expedient to transfix the lesion in several 



VERRUCA. 465 

directions with the long needles used in gynaecological practice, pre- 
viously dipped in a 50 per cent, solution of chromic acid. 

One may also transfix the base of the wart a sufficient number of 
times with a needle connected with the negative pole of a galvanic 
battery, the positive pole being connected with the body of the patient 
by the aid of a moist sponge. 

The formula according to w T hich are made several of the proprietary 
" wart-cures " sold in the shops is as follows : 



R Acid, salicylic, 3ss ; 

Cannabis Indie, extr., gr. v ; 

Collodion., gss ; 15 



33 
M. 



Sig. To be painted over the wart with a camel's-hair brush. 
For small multiple warts Morris recommends the following : 



R Glycerin., 


3jss ; 


6 


Acid, acetic, dil., 


Sijss ; 


10 


Sulphur, praecipit., 


3j; 


4 



M. 

For patches of warts Van Harlingen recommends cautiously attack- 
ing one part at a time with the following paste : 



R Pulv. acid, arseniosi, gr. vj ; 

Em|\as y t d hydrarg. , } ™ * s ' ad ^ ' ™ * s ' ad 8 



40 
M. 



Warts may also be treated by painting once daily with a saturated 
solution of potassium bichromate in boiling water. The liquid is 
applied cold. The application is painless and leaves no scar (Louvel- 
Dulongpre). 

For warts not requiring operative removal local treatment generally 
answers well. Those about the genital region often disappear if per- 
sistently washed with a solution of tannin in alcohol, 1 drachm (4.) to 
3 ounces (96.), after which they are dried and thoroughly dusted with 
boric acid, or salicylic acid with lycopodium, or burnt alum and rosin, 
or, what is most popular, dry calomel. Alum- and lead-lotions may 
also be substituted for the tannin and alcohol, and for a time be kept 
over the parts on a compress. 

Prognosis. — Warts are benignant growths ; in childhood and in 
early adult life they need not suggest grave sequels. It is far different 
in advanced years, for, though these excrescences possess even then no 
malignant character, they are frequent precursors of epithelioma. 
While it may justly be urged that the early lesions in such cases were 
really epitheliomatous and not verrucous, the fact remains that many 
warty formations of apparently benign character do in advanced years, 
especially when irritated by frequent caustic applications, undergo a 
cancerous metamorphosis. The tuberculous wart also may become the 
source of general tuberculous infection. 

Multiple Cutaneous Tumors accompanied by Intense Pru- 
ritus. — Under this title Hardaway, of St. Louis, described a rare 

30 



466 HYPERTROPHIES. 

disorder characterized by the occurrence of about sixty pea- to nut- 
sized, dense tubercles and tumors covered by a thickened, scaly, and 
excoriated, often hemorrhagic skin. In some situations coalescence 
had occurred, forming thus long and narrow plaques of nearly the 
width and of half the length of the finger of an adult. The lesions 
were seen upon the outer aspects of the arms and legs, the palms and 
soles, the sides of the fingers, and around the ankles, wrists, and' 
elbows. The accompanying pruritus was intense and intolerable ; and, 
having lasted for twenty-two years, it was associated with the degree 
of pigmentation often observed under similar conditions. The patient, 
who was an unmarried woman, fifty-one years of age, declared that 
the lesions first appeared as " blisters." 

Specimens of these tumors, microscopically examined by Heitzmann, 
exhibited hyperplasia of the epithelial and connective tissues. The 
papillae were longitudinally elongated, branching, and provided with 
narrow capillaries. Numerous nests, greatly varying in size and con- 
taining inflammatory elements with considerably enlarged blood-vessels, 
lay close beneath the papillary layer of the corium. These elements 
showed all stages of transition into basic substance. The deeper layers 
of the derma were built up of very coarse bundles of connective tissue 
and of numerous elastic fibres. 

Synovial Lesions of the Skin. — These cutaneous lesions possess 
importance from a diagnostic point of view. We have observed them 
in several individuals in whom the exact nature of the disorder had 
not been understood. They occur in the form of wart-like projections 
from the skin, pseudo-vesicles, and bullae, always over the site of bursas 
connected with tendons, traversing the small articulations of the hand 
and foot. They are seen over the metatarso-phalangeal articulations ; 
and in the hand most frequently over the dorsal face of the articulation 
between the distal and adjacent phalanges of the index-finger and 
thumb. The first form is that of a roundish, corneous, pea-sized wart 
with a yellowish centre, of long duration, usually insensitive unless 
roughly handled. When punctured a syrupy, yellowish, or grumous 
fluid exudes, which continues to form after repeated puncture. Split- 
pea-sized vesicles, and bullae as large as a small coin, often exceed- 
ingly painful, are also seen, especially upon the feet, with simply an 
epidermic roof-wall. Each lesion contains the same thickened, yel- 
lowish or whitish fluid, occasionally mingled with masses like sago- 
grains. In every case the contents of the lesions are supplied by a 
synovial bursa beneath the skin, with which the lesion is either directly 
connected or in communication by a short sinus. The treatment 
requires the complete excision or destruction of the secreting cyst-wall. 

Sidney Jones and Makins, of St. Thomas Hospital, exhibited several 
lesions of this character to the London Pathological Society. 

Papilloma. — This term has loosely been applied to a large number 
of cutaneous growths widely differing from each other, both histolog- 
ically and clinically. It has been made to include the vegetations of 
syphilis, the neoplasms of naevus, and even the tubercles of lupus. 



NJEVUS PIGMENTOSUS. 467 

The designation papilloma is properly limited here to such circum- 
scribed hypertrophies of portions of the skin as correspond with warts 
in their pathological significance. These growths may be defined as 
excrescences from the cutaneous surface, of a size considerably larger 
than that of any one of the varieties of wart with the exception of 
the condyloma, usually presenting a luxuriant growth composed of 
elongated papillae, blood-vessels, and enlarged rete, covered externally 
with a smooth epidermis like a pellicle, or, more commonly, branched 
and tufted with the cauliflower aspect, and then usually smeared with 
a puriform mucus. The tumor increases rapidly until it attains a 
maximum size, and then indolently persists. Lesions corresponding 
with this description occur in carcinoma, syphilis, and lupus. They 
may develop upon any portion of the body. 

Papilloma Area Elevatum (Beigel) is regarded by Crocker as 
an illustration of the results of the ingestion of one of the bromine 
salts, and this is well corroborated by the picture presented by one of 
our patients, in whom the face was covered with so-called "papil- 
lomatous " growths as a result of the administration of the salts of 
iodine. 1 

Papilloma Neuroticum is a term which has been applied to 
ribbon-like growths classed by some authors with ichthyosis hystrix. 
They properly belong, however, to the category of linear naevus. 

lOEVUS PIGMENTOSUS. 

(Lat. ncevus, a mask.) 

(Pigmentary Mole. Ger., Fleckenmal ; Fr., Tache 

Pigment aire.) 

Abnormal congenital pigmentations of the skin vary in color from 
a light-yellow or chocolate-brown to a blackish hue, and they may be 
single, or be multiple and very numerous. They vary in size from 
that of a pinhead to that of tumors of large volume ; and are either 
ovoid or circular in contour, or are so irregularly shaped as to present 
a fanciful resemblance to lower animals, whence the popular belief 
as to their origin in maternal impressions. They occur in both sexes, 
upon the face, neck, trunk, thighs, buttocks, and external genitals. 
The term N^vus Spilus is applied to those pigmentations which 
occur in a smooth and otherwise unaltered skin ; N^vus Verrucosus, 
to those which are irregular and wart-like ; Njevus Pilosus, to those 
surmounted by a growth of shorter or longer, stiff or downy, dark- 
colored hairs; and Njevus Mollusciformis, or Lipomatodes, to 
the soft or firm, more or less elevated and projecting tumors. ^ A case 
of unusually large congenital naevus lipomatodes associated with mul- 
tiple pigmentary nsevi of several forms, occurring in a child observed 
by one of us in 1883, 2 is represented among the illustrations of this 
treatise. The so-called "white moles" are similar to those described 

1 " Dermatitis Tuberosa, due to the Ingestion of the Iodine Compounds," Med. 
News, Oct. 13, 1888 ; illustrated in color from a painting in oil. 
2 Jour. Cutan. and Ven. Dis., July, 1885. 



468 HYPERTROPHIES. 

above, except that the pigmentation is very slight or apparently 
wanting. 

Linear N^vus (Morrow), 1 N^vus Unius Lateris, N^vus 
Verrucosus, N^evus Nervosus, Njevus Lichenoides Ichthyosis 
Cornea, Ichthyosis Linearis Neuropathica, Papilloma Neu- 
ropathicum Unilaterale. — Moles may be, when multiple, sym- 
metrically or asymmetrically developed upon the surface of the body ; 
and in either case may exhibit an arrangement suggesting the control- 
ling effect of the nervous system. 

In a case reported by one of us 2 there were multiple monolateral 
pigmentary nsevi distributed over the left side of the trunk in the 
course of the intercostal nerves, and in such a manner as strongly to 
suggest to the eye their correspondence in site with the lesions of 
zoster of the same region. De Amicis 3 had previously reported a 
somewhat similar case. Many other cases have been recorded in 
which pigmentary and verrucous nsevi, consisting of variously sized 
and shaped lesions, were arranged in lines or streaks, usually on one 
side only of the body, and often along the course of one or more nerves. 
Selhorst 4 and Thibierge 5 have reported cases of this type in which 
involvement of sebaceous glands produced acneiform lesions. 

Nsevi seem to occur with equal frequency in the two sexes, and 
though they usually appear at birth or soon after, they are sometimes 
first seen at puberty or even later in life. It is possible that they may 
be acquired after birth, as claimed by some authors; but it is much 
more probable that such presumably acquired cases are instances of 
rapid development from minute congenital pigmentary moles. 

The tendency of pigmentary nsevi, after attaining full evolution, 
is to persist unchanged for a lifetime. Their increase in persons of 
tender years is occasionally characterized by a relative rapidity of 
growth. A pilary nsevus upon the cheek of an infant may extend over 
nearly double its original area in the course of two years. In adults 
an increase in the size of these growths is unusual but does sometimes 
occur. Degenerative changes are possible. In the young there may 
be spontaneous gangrene or rapid necrosis following slight injury of the 
nsevns. In older people there may be a malignant transformation into 
carcinoma or pigmented sarcoma. 

Pathology. — Anatomically, pigmentary moles are readily separable 
into two classes : first, those in which the pigment only of the skin 
undergoes hypertrophy (nsevus spilus) ; second, those in which there is 
always hypertrophy of the epidermis, together with a varying amount 
of hyperplasia of the papillae, vessels, glands, or hair-follicles. The 
histopathology thus varies greatly in different cases, depending upon 
the extent to which these different elements of the skin are involved. 
The distinction made by v. Barensprung, Gerhardt, and others between 
these two classes and still a third, in which the lesions are limited to 



1 K Y. Med. Jour., Jan. 1, 1898. 

2 Chicago Med. Jour, and Exam., Oct., 1877. 

3 Lo Sperimentale, March, 1876. 

4 Brit. Jour, of Derm., 1896. 

5 Annal. de Derm, et de Syph., 1896. 



ACANTHOSIS NIGRICANS. 469 

the cutaneous regions supplied by one or several nerves (linear nsevus, 
etc.) is more apparent than real : for there is probably a trophoneurotic 
influence exerted in all cases, even in the enormous tumors of a mol- 
lusciform type. According to Demieville, the pigment-accumulation 
occurs in the corium as well as in the epidermis, in the form of ribands 
stretching along the lines of the blood-vessels. Kaposi holds that 
moles as well as nsevi result from a retained foetal impulse to develop- 
ment on the part of the cellular elements of the nsevus, which carries 
them beyond the normal limits of growth. 

Treatment. — Pigmentary moles very rarely spontaneously disap- 
pear. Their removal may be accomplished by excision, or by destruc- 
tion with caustics, with the Paquelin knife, or with the needle by elec- 
trolysis. The last-named method is applicable only to the smaller and 
more superficial growths of this class. Fox 1 calls attention, in connec- 
tion with this subject, to the need of passing the needle no deeper than 
the epidermis, sufficiently deep merely to " blister the surface of the 
black spot." 

ACANTHOSIS NIGRICANS. 

Under this title Pollitzer and Janovsky 2 describe cases which at 
present it is difficult to recognize as instances of ichthyosis, of verruca, 
or of nsevus pigmentosus. Morris, 3 Pye-Smith, Darier, Spietschka, 4 
and others have since reported cases, numbering in all about thirty. 
In these patients the neck, the mouth, parts of the trunk, genito-crural 
and anal regions, hands, axillae, and thighs displayed yellow and grayish- 
brown to almost black pigmented areas, covered in some places by fine 
papillary projections, some of which were scattered and discrete, while 
those situated in the axillae, the groins, and the flexor surfaces of the 
joints were grouped and coalesced to form papillomatous, vegetating 
masses. In places there was simple exaggeration of the natural lines 
of the skin, in other parts there were ridges radiating from a central 
point. The mucous surfaces also were involved. Over the hands of 
one patient the color was deepest along the lines of the veins; and 
there was a glassy shimmer to the prominent normal areas of the 
cuticle. In Morris's case the pigmentation and warty growths were 
not always associated, there being a few sites of pigmentation in an 
otherwise normal skin, or in which there were unpigmented warty 
growths. 

In sections made of the skin removed from one patient there were 
recognized dilatation of the blood-vessels and lymph-spaces in the 
papillary and subpapillary layers; increase of pigment-cells ; enormous 
thickening of papillae and epidermis ; elongation and bifurcation of the 
rete-pegs, and some "suggestions" of epithelial pearls. A few colonies 
of bacilli having the shape of short, thick rods were discovered, but not 
in all the secretions examined. In several cases the condition has been 
associated with abdominal carcinoma. 

1 Electricity in Removal of Superfluous Hairs, etc. Detroit, 1886. 

2 Internat. Atlas of Rare Skin-diseases, 1890, iv., ii. 

3 Medico-Chirurgical Transactions, vol. lxxvii. 

4 Arch. f. Derm. u. Syph.. 1898, Bd. xliv., S. 247. 



470 HYPERTROPHIES. 

XEROSIS. 

(Gr. Zvpk, dry.) 

(Xeroderma.) 

Xerosis is a term which has been applied to the disease sometimes 
known as Xeroderma pigmentosum, or the Melanosis lenticularis pro- 
gressiva of Pick. Xerosis has also been used as practically equivalent 
to ichthyosis. 

In these pages the term is used to describe a condition included by 
most authors under the title of ichthyosis, which in many cases it really 
is ; but in others the appearance of the integument is to be distinguished 
from that seen in the typical ichthyotic skin. The condition to which 
the name xerosis is here given is one intermediate between keratosis 
pilaris and ichthyosis simplex. 

Symptoms. — The sole symptoms of xerosis are cutaneous. The 
skin of the body, in some regions more than others but at times univer- 
sally, is to the touch dry, harsh, rough, and destitute of natural moisture 
and unguent. Closely inspected the skin-surface is seen to be scaly, 
exfoliation being of the character described as furfuraceous. In some 
cases the hand passed briskly over the surface of such a skin will cause 
separation of scales in a scanty shower ; in other cases, while the sur- 
face seems ready for the furnishing of such flakes of epidermis, one is 
surprised to note that they are more or less attached, and the clothing 
of the patient is not, as in some forms of psoriasic and pityriasic dis- 
ease, covered with epidermal scales. In brief, there is not in progress 
a catarrh of the horny layer, as in some of the other disorders named ; 
but there is merely an unusual keratinic transformation of the elements 
of that layer. 

The parts chiefly involved are the extremities, more particularly the 
hands, feet, forearms, and legs ; but all parts of the skin may be in- 
volved, including the face, temples, cheeks, and even the lips. 

The disorder is met with in all grades, from the mildest physiological 
dryness suggestive of so-called " goose-flesh," to that state in which the 
face only indicates an abnormal condition of the skin. The color of the 
integument in well-marked cases is always of a dirty-yellowish or dirty- 
brownish shade, suggesting an unwashed condition, and in extreme cases, 
usually those of older patients, the skin becomes rather deeply pigmented. 
The affection is seen in both sexes and at all ages, being a congenital 
condition the first appearance of which is clearly indicated only after 
variable periods of time after birth. Red-haired individuals perhaps 
furnish the larger number of well-marked cases. The general health 
is unaffected. Before puberty the affection in northern latitudes will 
often be inappreciable in summer and distinct in winter. As maturity 
is reached, however, the condition may become permanent. 

This disorder is described by some authors as a variety of ichthyosis 
simplex, but the reasons for giving it separate consideration are that 
the disease does not furnish the typical plate-like scales of ichthyosis ; 
and one child affected with what appears at first to be merely xerosis 
may exhibit a typical ' ichthyosis before puberty, while another will go 



ICHTHYOSIS. 471 

through life, the xerosis of his childhood becoming simply the extreme 
xerosis of mature years, but never an ichthyosis. 

Xeroderma may, therefore, be regarded in one sense as a variety of 
ichthyosis, but it should not be described as a stage of the latter 
disease. 

The disorder is congenital, and is readily distinguished from all fur- 
furaceous scaling diseases of the skin by the absence of inflammation. 

The Treatment and Prognosis are those of the disease next to be 
considered. 

ICHTHYOSIS. 

(Gr. ix^vc, a fish. ) 

(Fish-skin Disease, Xeroderma. Ger., Fischschuppenausschlag ; 
Fr.j Ichthyose ; ItaL, Ittiosi.) 

Symptoms. — This disorder displays a wide variation in its symp- 
toms. To the extremes in either direction two names are given, ich- 
thyosis simplex and ichthyosis hystrix. 

Ichthyosis Simplex. — The earliest and mildest form of ichthyosis 
simplex is, by many authors, held to be the condition of xerosis de- 
scribed in the preceding pages. It will be remembered, however, 
that such a xerosis may persist through life without the production at 
any time of the peculiar symptoms of the ichthyotic skin. In these 
earlier manifestations of the disease, then, the skin of the patient can 
merely be described as unusually harsh to the touch, moistureless, and 
covered with adherent or exfoliating fine scales. The scales are not 
massed, imbricated, nor displayed in plaques, and usually are of a dull 
yellowish-white color. It is rare that the practitioner is consulted for 
the relief of this disorder ; it is usually discovered when the skin is 
exposed for other purposes (exploration, vaccination, etc.). In a still 
more advanced degree the scales are massed, forming grayish and 
whitish, polyhedral elevations or plaques, regularly outlined and 
closely set together, especially upon the extremities and certain por- 
tions of the trunk ; elsewhere the scaliness described above may be 
present in a more marked degree. Variations occur, in consequence 
of which the plaques, bordered distinctly by the natural lines and fur- 
rows of the skin, are even depressed, centrally or completely, or they 
assume darker shades of color — viz., brownish and greenish-brown. 

Ichthyosis Hystrix. — With and without the symptoms detailed 
above, the hypertrophy of the skin may, in circumscribed patches or 
larger areas, produce irregularly shaped, verrucous, corneous, corrugated, 
wrinkled, or rugous masses, usually much darker in color than the 
patches seen in the simple variety of the disease, and more often also 
discovered in adult years. The resemblance is here rather to the 
rough bark of a tree than to the scales of a fish. In still rarer cases 
the excrescences assume a spinous, acuminate, or horn-shaped form. 
The hand passed over the skin-surface perceives not only the excessive 
roughness, but also the dryness of the skin. Perspiration in some 
cases is imperceptible in the parts affected. The nails are friable and 



472 



HYPERTROPHIES. 



indurated ; the scalp is scaly and covered with hairs of exceeding 
harshness. The palms and soles are often spared. Kaposi describes 
certain diffuse callosities occurring in the palmar and plantar regions 
differing from ichthyotic patches elsewhere. The face is usually spared, 
but, when involved, only the slighter manifestations of the disease appear 
there — minute, superficial, scaly patches of a grayish tint." 

Later studies of the hystrix type of ichthyosis have led to a modi- 
fication of the view formerly held. To-day many disorders to which 



Fig. 56. 




Ichthyosis hystrix. 

the name ichthyosis hystrix was once given are classed with congenital 
warts, psorospermosis follicularis, nsevus unius lateris, and other simi- 
lar affections. 

Ichthyosis is accompanied by insignificant subjective sensations. 
The skin, indeed, of these patients may be free from the eczematous and 
other complications of the less diffuse keratoses. In four ichthyotic 
patients who were syphilitic there was a decided tendency to the pro- 
duction of lesions of the mucous surface without cutaneous efflorescence. 



ICHTHYOSIS. 



473 



The extensor are usually more implicated than the flexor surfaces of 
the extremities. 

Variations from the types described above are noted by observers. 
Hibert l for example, in a case of congenital circumscribed ichthyosis 
in a young woman, discovered a growth of thick hairs, one centimetre 
long, over the left shoulder and arm. Weisse 2 exhibited to the New 
York Dermatological Society a boy, ten years old, with hemorrhagic 
fissures in an ichthyotic skin, double ectropion, corneal opacities, claw- 
like fingers, attachment of the ears to the sides of the head, and a gen- 
eralized condition of the skin which became very red when warm, some 

Fig. 57. 



d— 




Ichthyosis hystrix, vertical section : a, masses developed from the stratum corneum ; b, cones 
formed by the re'te ; c, hypertrophied papillae with dilated vessels; d, dense connective tissue of 
corium, exhibiting numerous vessels transversely divided. (After Kaposi.) 

doubt however existing as to the diagnosis. Extreme types of ich- 
thyosis are seen in the so-called " porcupine," " rhinoceros," or " hedge- 
hog" patients. In these unfortunate beings the entire skin is con- 
verted into a rugged, bristling, warty, quilled, or horn-like envelope, 
suggesting the integument of the animals named. The terms Ichthyosis 
Serpentina, Nacrea, and Nigricans are employed to designate those con- 
ditions, respectively, in which is recognized a snake-like appearance of 
the skin, silvery whiteness of the scales, or a dark pigmentation. 

1 Virchow's Archiv., September 3, 1884, Bd. xcix. 

2 Jour. Cutan. and Yen. Dis., 1883, p. 49. 



474 HYPERTROPHIES. 

Ichthyosis Congenita (" Harlequin " Fcetus). — This exceed- 
ingly rare deformity occurs as an intra-uterine modification of the skin 
of the foetus, which is usually brought into the world as a non-viable 
monstrosity. The skin is represented by a thick, horny cuirass, deeply 
furrowed and resembling plates of armor. Large flakes of corneous 
epidermis, but partially attached to the corium, present their broad, 
free edges to the outer world. The ears, eyelids, and lips are usually 
wanting, being replaced by corneous folds suggesting in appearance 
the corresponding features of a mummy. The fingers and toes resem- 
ble talons and claws. Death commonly occurs in the course of a few 
days from inability to secure nutrition by the act of sucking and from 
imperfect development of other organs than the skin. Bo wen l believes 
that some of these deformities are due to a persistence of the epitrichial 
layer of the foetus. 

Sherwell 2 describes a case of congenital ichthyosis of unusual in- 
terest from the fact that at the time of the report the infant had lived 
to be more than five months old, and seemed to be gaining in strength 
and improving in the condition of the skin. No history of heredity or 
of a family tendency to deformities of the skin could be obtained. 

Ichthyosis Lingua ("psoriasis of the tongue") is a disorder 
described by the French under the title leucoplasie. It is not a variety 
of ichthyosis. (Cf. Lichen planus of the mucous membranes.) 

Viewing ichthyosis as thus exhibited in various manifestations, it 
is seen to be a congenital deformity rather than a disease. It may be 
partial or general, though usually the latter, with intense manifestations 
over the extremities, especially over the extensor aspects ; and relative 
immunity of the face, the axilla?, the groins, the flexor aspects of the 
limbs, the palms and soles, the glans penis, and the prepuce. Like 
xerosis, the deformity is rarely visible at birth, but usually becomes 
apparent before completion of the first year of life. It is first man- 
ifested in the regions of election named above — i. e., over the elbows 
and the knees — and here also, as in xerosis, it may for some years 
only be apparent in northern latitudes in winter, disappearing almost 
wholly in the summer season. When maturity is reached the deformity 
has been known to disappear temporarily under the influence of inter- 
current disease (variola). One patient is said to have regularly cast a 
slough of his integument in the autumn. The general health is usually 
unimpaired. 

Etiology. — Ichthyosis is unquestionably a congenital disease, though 
its first manifestations are apparent only during the second year of life. 
It is said to be generally hereditary, but this statement should be ac- 
cepted with some reserve for every individual case. One ichthyotic 
patient, married to his cousin, had by her five children entirely free 
from cutaneous disease. None of his parents or grandparents was simi- 
larly affected. The disease occurs equally in both sexes, and is liable 
to aggravation in cold climates and during the season of winter. The 
general vigor and development of patients thus deformed are, as a rule, 

1 Jour. Cutan. and Gen.-Urin. Dis., 1895. 

2 Ibid., 1894, p. 385. 



ICHTHYOSIS. 475 

unimpaired. Kaposi says : " The cause appears to be a local anomaly 
of the nutrition of the skin, especially involving its epidermic and 
fatty elements." 

Thost l describes ichthyosis occurring in four generations. Accord- 
ing to the ascertained genealogy, the ancestor first known to have suf- 
fered from this affection had five male children who inherited it, while 
one girl and one boy were spared. One of these affected subjects had 
five children, of whom three males showed the anomaly, w T hile one boy 
and one girl remained free. Another brother, of the second genera- 
tion, had five male and three female children ; of these, four boys and 
two girls became affected. One of the latter (of third generation) 
bore four children, of whom three girls inherited the disease, while the 
fourth, a boy, escaped. It appeared that the affection always showed 
itself within a few weeks after birth, in the form of a roughness of the 
palmar and plantar surface. With the growth of the patient the con- 
dition constantly increased in severity, the epidermis shedding in large 
shreds, until the disease reached its maximum by the fourteenth year. 
There was a marked disposition to excessive sweating, particularly in 
the diseased localities ; the sensibility of the skin remained normal. 
Microscopic examination showed, in addition to hypertrophied papillae, 
great development of the sw r eat-glands, with marked thickening of the 
ducts. Treatment failed to give more than partial relief. 

In the Molucca Islands and some other isolated regions ichthyosis, 
on account of its unusual prevalence, has been regarded as an endemic 
affection ; but instances of this kind are readily explained, without 
referring to climatic influences, by the operation of heredity and inter- 
marriages. 

Pathology. In the mild forms Unna describes an immediate for- 
mation of the horny layer from the rete without the intervention of 
keratohyalin. It is a complete cornification, the horny cells being 
homogeneous and containing no nuclear remnants. In this respect 
the hyperkeratosis is unusual, and contrary to the belief of many 
observers that cornification is impossible without the intervention 
of the keratohyalin of the granular layer. The rete is thinned more 
from an atrophic condition of the cells than from an actual diminution 
of their number, though this does occur sometimes, so that only one or 
two layers of cells cover the papillary tips. The lymph-spaces are also 
very small. The extremities of both the rete-pegs and papillae are 
broad and flattened and their necks narrowed, so that they suggest a 
dove-tailed appearance. The coil-glands possess a swollen epithelium 
and a widened lumen resembling their excretory ducts, which exhibit 
less functional activity. The collagenous fibres are thickened at the 
expense of elastic, fatty, and lymphatic structures, and there may 
be a chronic low grade of papillary and perifollicular inflammation 
without plasma-cells and with only a few mast-cells. The follicle- 
mouths either w r ere dilated with a broad horny plug, or were closed, 
retaining the plug in the dilated neck. In severe forms is noted a 
proliferating rete with reappearance of the granular layer and a deeper 
dipping down of horny substance, the cutis containing many plasma- 

ilnaug. Diss., Heidelberg, 1880; Centralbl. f. Chir., 1881, No. 10. 



476 HYPERTROPHIES. 

and mast-cells. In these severe forms there is less superficial exfolia- 
tion, the dryness characteristic of the mild forms is wanting, and the 
condition is readily transformed into the clinical crusting type known 
as " ichthyotic eczema." 

Ichthyosis hystrix has, according to Kaposi, the anatomical structure 
of all warts. Crocker finds that the lesions differ from plane warts in 
that the horny formation dips down deeply along the papillae. 

Ichthyosis congenita is believed by Bo wen 1 to be due to a per- 
sistence of the epitrichial layer of the foetus. Wassmuth 2 has pub- 
lished the results of a study of a case of ichthyosis congenita (hyper- 
keratosis diffusa congenita). He found the changes limited almost 
entirely to the epidermis, the cutis showing only an insignificant chronic 
inflammation of low grade. As compared with normal skin, the pap- 
illae were much more numerous, broader and flatter, with greater irregu- 
larity in form and size. The layers of the rete were thickened and the 
cells of the epithelial pegs assumed a spindle form. Nearer the surface 
they became polygonal. A granular layer could be made out definitely 
only on the scalp. The horny layer varied in thickness on different 
portions of the body, but averaged two hundred times thicker than 
normal. The sweat-glands were greatly increased in number, but 
otherwise normal. Deformities of the sebaceous glands were caused 
sometimes by keratinization of the follicle-mouths. The hairs grew 
quite normally except for their deformed shape, caused by the thick 
and dense horny layer. 

Diagnosis. — Ichthyosis not only presents features which are so 
characteristic as to be unmistakable, but also those which can be well- 
nigh perfectly portrayed in plates. In this respect it differs from a 
long list of cutaneous maladies. 3 

Whenever necessary in the establishment of a diagnosis, aid of an 
important character can be obtained in the history of the disease and in 
recognition of the absence of the lesions and lesion-sequels exhibited in 
the exudative and scaling affections heretofore considered. The most 
conspicuous characteristic of ichthyosis as distinguished from psoriasis, 
lichen ruber, and pityriasis, is the absence of inflammatory phenomena. 

Treatment. — The younger the patient applying for relief the larger 
are the chances of improvement and of possible recovery. Ichthyosis 
hystrix of mature years is practically incurable. Internal treatment is 
valueless. External treatment is directed to softening, macerating, or 
anointing the skin, and, so far as practicable, to preserving it in a softer 
state. This softening is accomplished by frequent baths, alkaline, 
vaporous, or combined with the use of soap or green soap, and generally 
followed by an anointing with vaselin, dilute glycerin, or lard. The 
French, after the removal of the denser layers of the horny plates with 
the aid of soft soap and water, anoint the body by friction with glycer- 
olate of starch. Almond-, cod-liver, linseed-oil, or lanolin may be 
used after the bath. Only by the most assiduous perseverance is a 
desirable result obtained and permanently secured. In the severe 

1 Jour. Cutan. and Gen.-Urin. Dis., Dec, 1895. 

2 Beitrage zur path. Anat. und allgemein. Path., 1899, p. 19. 

3 Cf. portrait of- the ichthyotic skin in Plate F of Duhring's Atlas. 



ONYCHA UXIS. 477 

hystrix varieties the most annoying projections and rugosities may be 
removed by excision, by the Paquelin knife, or, less preferably, by the 
aid of caustics. 

Subcutaneous injections of 1 grain (0.06) of pilocarpine have been 
practised in ichthyosis, in order to induce sweating, with a view to 
maceration of the skin. Van Harlingen recommends the following for 
use when the epidermis begins to shed after the application of soft soap : 



R 



Potass, iodid., 




Bj; 


l 


01. pedis bubuli, 
Adipis, 


} 


aa ^ss ; 


aa 15 


Glycerin., 




3j; 


4 



33 



M. 



Anderson recommends the wearing of pure vulcanized India-rubber 
garments, a method of treatment too exhausting for all cases. 

Taking a general survey of the therapeutic management of ichthy- 
osis and its results, the course to be advised for the majority of patients 
is clear. With but few exceptions, the subjects of this deformity are 
either entirely relieved or greatly better during hot weather and in 
moist atmospheres. Marked exceptions to this rule, however, occur. 
Under these circumstances, and having regard to the essential fact that 
the deformity is lifelong in duration, patients should always, when prac- 
ticable, select for permanent residence a climate most conducive to the 
comfort of the skin. There is no step which the ichthyotic patient can 
take comparable in value with the selection of a suitable environment. 

Prognosis. — Having in view the facts set forth above, it will be 
clear that in no case can a favorable result be anticipated with respect 
to a " cure " of the deformity. Treatment, persistent, prolonged, and 
properly directed in connection with suitable climatic influences, may 
do much to improve the condition of the skin. 

ONYCHAUXIS. 

(Gr. bvv^ a nail ; avtjea), to grow. ) 

Symptoms. — This may be a congenital or acquired disorder. The 
nail-substance may be developed to an unusual extent either as an idio- 
pathic or as a symptomatic affection, and in each case the nails may simply 
be increased in volume, extent, or number, or may exhibit such increase 
in connection with secondary changes. Thus, the nail may develop to 
an extraordinary length or breadth, preserving its general character as 
regards texture, color, and position ; or it may also be changed in any 
particular, becoming opaque, discolored, dirty yellowish, and blackish 
or brownish ; rugous, furrowed, horny, and rigid ; thickened in one 
part and thin, vitreous, and extremely fragile in another ; tilted to one 
i side or the other on its bed ; or projected backward in recurved, 
irregular lines. Finally, the matrix may be inflamed, suppurating, 
hemorrhagic, or the seat of an excruciating pain. One or more of the 
nails may be affected ; in some cases the entire twenty are similarly 
involved. The conditions of hypertrophy, atrophy, and dystrophy of 
the nails are frequently present in a single case, and it is often difficult 
to say which process is the most prominent, 



478 HYPERTROPHIES. 

The diseases in which these changes occur as symptomatic lesions 
are numerous, since it is evident that the matrix, from which the nail 
is produced, would scarcely enjoy immunity in the case of profound 
alteration of the skin in its vicinage. Thus, eczema, lepra, psoriasis, 
lichen ruber, syphilis, scarlatina, perforating disease of the foot, va- 
riola, and other diseases are attended by changes of various grades of 
severity in both matrix and nail. 

In the condition termed Paronychia (Whitlow) one or both 
lateral borders of the nail bury themselves deeply in the tissues adja- 
cent, producing thus an exquisitely tender and painful state of the 
soft parts, which may suppurate or surround the attached flange of the 
nail with exuberant granulations. This condition is more frequently 
observed in the nails of the toes, as these appendages of the skin of the 
feet are liable to injury from the pressure of ill-fitting boots, gaiters, 
or shoes. In the condition described as Onychia the matrix is not 
only inflamed, but the nail-substance is, as a consequence, texturally 
changed. No strict line of demarcation, however, can be described 
between the two conditions. The term Onychogryphosis has been 
employed to describe the contorted deformities which cause the nail to 
resemble a claw. 

Onychomycosis is the name given to that condition in which the 
nail-substance is invaded by vegetable parasites. In such cases the 
nails become opaque, discolored, and thickened, with a noticeable fria- 
bility at the projecting border. 

Syphilitic Onychia is the condition in which one or several of 
the nails may become affected, though it is quite characteristic of the 
disease to exhibit limitation to the extremity of a single digit. In 
such a case there is usually a marked involvement of the peripheral soft 
parts, which may be infiltrated with gummatous material, though the 
nails may be extensively damaged when the soft parts of the fingers are 
apparently normal. The bullous syphiloderm, among the congenital 
manifestations of the disease, will at times form beneath or quite near 
the nail, thus endangering its integrity. In both forms ulcerative 
results are common, with secretion of a foul discharge. 

In the affection termed " perforating disease of the foot " all the 
nails of the organ affected may exhibit a characteristic onychauxis or 
dystrophy. 

Traumatism (constant or intermittent pressure of shoes) may aug- 
ment the size of the nail in one or another diameter ; and the deformed 
talons resulting from gross and long-continued neglect (East Indian 
devotees, etc.) are illustrations of another type of hyperplasia. Super- 
numerary nails may be found on supernumerary fingers and toes ; or 
double organs on a single digit ; or in unusual situations, as over the 
scapula (Tulpius) ; or on a digital stump ; or in an ovarian cyst. 

With respect to onychauxis proper, two forms are recognized : in 
the first, the nail-cells are more closely set together and the resulting 
hypertrophy is declared, not in changes in bulk of the nail, but in a 
dense, thick, opaque, glossy, grayish-white transformation of the organ. 
The nail is perceptibly increased in weight and becomes so solid that it 
cannot be cut with ordinary implements. It may be also, though not 



PLATE XI. 




Syphilis of the Nails. 

I (From a photograph.) | 



ONYCHA UXIS. 479 

changed in bulk, altered in shape, its free border being curved down- 
ward or upward. 

The second form represents a visible hypertrophy in bulk, the nail 
being enlarged in one or several diameters. Enlargement in a trans- 
verse diameter necessarily involves the soft parts adjoining. Vertical 
hypertrophy results in any one of the claw- or talon-like forms of 
onychogryphosis. 

Etiology. — Onychauxis may be congenital or acquired, idiopathic 
or symptomatic, and be due to inflammatory changes in the corium or 
matrix of the nail ; to traumatism ; to defective hygienic care of the 
general surface of the skin, including the nails ; and perhaps, in ex- 
ceptional cases, to senile influences. 

Treatment. — The treatment of the disorders of the nails described 
above is largely that of the maladies in which they occur. Arsenic 
and iron are often indicated in these aifections, and their influence upon 
the nutrition of the nail cannot be questioned. In syphilitic onychia 
the constitutional treatment of the disease is essential. The cutting, 
scraping, and trimming of the nail with the aid of the useful instru- 
ments found in the chirop<Klist's case are important measures in many 
patients. 

The treatment of ingrowing toenail varies with the extent of the 
disease. In mild cases soft threads of charpie are insinuated between 
the offending border of the nail and the tender surface upon which it 
presses. Counter-pressure by plaster and the local use of a crayon 
of silver nitrate may be at times employed with advantage. In severe 
cases the nail mav be removed, though this is generally unwise. The 
soft parts are, by some surgeons, completely removed from the side of 
the nail by means of a thin-bladed bistoury, and the nail permitted to 
grow down upon one side of the extremity of the distal phalanx, thus 
protecting the cicatrix and radically preventing recurrence of the 
disease. 

The proper dressing of the feet in onychauxis of the toes is a matter 
of great importance. The shoes and socks or stockings should be ad- 
justed both as to texture and shape to the special requirements of each 
case. After the hypertrophied tissue is largely removed by cutting or 
scraping the phalanx may be enveloped in a plaster-mull or salve- 
muslin of diachylon ointment, or with mercurial plaster, and the whole 
be covered with a leather or a rubber cot. 

The Prognosis in these disorders of the nails rests entirely upon 
the nature of the malady in which they occur. Idiopathic and localized 
changes, as also those occurring in transient cutaneous diseases (e. g., 
the exanthemata), often terminate favorably. In severe constitutional 
or grave cutaneous diseases the outlook is less promising. The diseases 
of the nail are usually more obstinate and less amenable to treatment 
than the similar affections of the softer parts. In cases in which there 
is congenital disease of the nails a prognosis should be made with 
reserve. 



480 



HYPERTROPHIES. 



Fig. 58. 



HYPERTRICHOSIS. 

(Gr. virepj in excess ; dpi!;, hair.) 

(Hypertrophy of the Hair, Hairiness, Hirsuties, Hyper- 
trichosis, Polytrichia, Trichauxis. Fr., Poils acci- 

DENTELS.) 

This anomaly may be congenital, and may occur in various 
grades. It is common to see infants at birth with extremely long 

hairs on the hairy part of the 
body, this growth being usually 
replaced later by shorter fila- 
ments. Universal congenital hir- 
suties is a rare deformity, the 
entire body being then covered 
with longer or shorter downy 
hairs of various colors. 

Acquired hirsuties may be par- 
tial or universal, much more com- 
monly the former. Thus, the 
hairs of the scalp or the beard 
may acquire an enormous vigor 
and length, reaching to the 
ground when the body is in the 
erect position ; or the hypertrophy 
of the hairs may affect the face 
of the child or the woman ; and 
in persons of the sex last named 
either the upper lip, chin, cheeks, 
or all portions of the body usually covered by hairs in man, may be 
provided with a vigorously and symmetrically developed pilary growth. 
Remarkable instances of universal congenital hirsuties are occasion- 
ally observed. The so-called "Russian dog-faced man" (Andrian 
Jeftichjew) and his son were noteworthy illustrations of this anomaly. 
In most cases the influence of heredity is distinct and is often accom- 
panied by defective dental development, such as entire absence of 
molar or of canine teeth. In all cases of hypertrichosis, whether con- 
genital or acquired, the parts normally unprovided with hair are not 
the seat of the pilosis. 

As the growth of the beard in man is more or less associated with 
the maturity of the sexual organs, so the hypertrichosis of women and 
children is at times related to a precocious, perverted, or arrested func- 
tion of the generative organs. The reported instances of menstruation 
in female infants and children usually include a description of abnormal 
pilary development about prematurely developed pudenda; and after 
the climacteric period, when some women conspicuously in external 
appearance begin to resemble individuals of the opposite sex, either 
isolated, thick, bristle-like hairs develop over the chin or lips, or the 
extreme hirsute condition may be reached. Duhring 1 reported one 

. ^rch. of Derm., April, 1877. 




The Russian "Doer-faced Man. 



HYPERTRICHOSIS. 481 

such case, which is illustrated by a lithograph representing the face of 
a woman provided with a superb beard. 

The influence of the sexual organs in the hypertrichosis of women is 
well demonstrated in the following case coming under our observation : 

A married woman, thirty-three years of age, weighing one hundred 
and fifty pounds, mother of three healthy children, applied for relief 
of a general and facial hirsuties which had resulted in the growth of a 
full beard and moustache. She had not menstruated for more than a 
year, and had been pronounced by an expert to be past the climacteric. 
During 1884 and 1885 the hairs of the face were removed in succes- 
sive operations by the electrolytic method described below. Menstrua- 
tion began while she was subject to the influence of the galvanic cur- 
rent in the operating-chair, and continued thereafter irregularly, at 
times with intense pain and even menorrhagia. In 1886, after the last 
of the operations on the face, she rather suddenly lost in weight, 
decreasing to one hundred pounds, and began to menstruate regularly 
and painlessly. The hypertrichosis of the general surface then spon- 
taneously disappeared. In the latter part of the year she again con- 
ceived, and in March, 1887, being then free from any form of hirsuties, 
she brought a healthy male child into the world. 

As the result of the persistent application of stimulating and oily 
liniments over a region of the body (scapula, sacrum, sciatic notch, etc.), 
as also after traumatism by pressure or otherwise, a growth of long and 
numerous hairs is often produced. Care should be had in the manage- 
ment of cases of acne and rosacea in the persons of dark-skinned 
young women with luxuriant hair upon the head, lest a similar growth 
be produced upon the chin, cheeks, or nose. 

In cases of hypertrichosis the hairs may be colored variously, and 
the hypertrophy of dow T ny hairs purely be numerical, or result in 
increase in the actual size of the shaft of the individual filaments. In 
neither case do the hairs present any anatomical peculiarities of struc- 
ture. The localized congenital form of hirsuties is often characteristic 
of certain moles, known as N-ZEVi Pilosi. The surface of pigmentary 
moles (N^evi Pigmentosa) is often very extensively covered with hairs 
of a dark color. Singular anomalies have been figured in which exten- 
sive regions (one or several limbs, the entire back, even the greater 
part of the body) were the seat of enormous pigmented moles, covered 
with warts, fibromata, and other benign tumors, and clothed with a 
thick covering of longer or shorter hairs. 1 All such cases exhibit a 
striking development in either symmetrically or asymmetrically dis- 
posed areas of distribution of cutaneous nerves. 

The Hypertrichosis Neurotica of authors is that condition in 
I which an excessive growth of hair has succeeded spinal paralysis and 
i other morbid conditions of the nervous centres. Under the title Tro- 
phoneuroses of the Skin in this work are described changes of a similar 
kind, in which there is association of hypertrichosis with hyperidrosis, 
changes in the nails, and even extensive tylosis of the palms and soles. 

Plica Polonica was formerly supposed to be a disease peculiar to 

1 See the authors' case of nsevus lipomatodes in a child, the pilary growth being at 
1 that age undeveloped. Jour. Cutan. and Ven. Dis., July, 1885. 

31 



482 HYPERTROPHIES. 

Poles (whence its name), but which has long been recognized as a re- 
sult merely of persistent neglect, filth, the invasion by parasites, and 
consequent exudative disorders of the scalp. When it exists the hairs 
form a huge matted mass on the crown of the head. Hebra devotes an 
interesting chapter to the superstitious awe with which this accumula- 
tion of hairs, lice, and filth has been regarded. In Alaska a number 
of cases of plica have been observed among the natives of that region. 
A typical case of this deformity was lately presented at our clinic. 

Neuropathic Plica. — Le Page l described a case in which tangled 
" lumps " and " festoons " of hairs, flat, curled, looped, and inter- 
twined appeared on one side of the head of a girl seventeen years old, 
who had previously suffered from neuralgic pains in the site of the 
growth. 

Etiology. — The causes of hypertrichosis are obscure. It is clear that 
whatever determines the blood in excess to any region of the body sup- 
plied with hair-follicles may indirectly be the cause of hypertrophy of 
hair, a fact demonstrated in patients who, after applying sinapisms 
or liniments for years to the skin over the seat of a rebellious neuralgia, 
exhibit in this region an abundant growth of hair, often several inches 
in length. In women, whose sex renders the anomaly most deforming 
and distressing, it is noted, as has been observed, in precocious, per- 
verted, or arrested activity of the sexual function. It may be a racial 
peculiarity, a family trait, an inherited anomaly, or an epiphenomenon 
in dwarfs, monsters, individuals affected with club-foot, insanity, and 
congenital deformities of several kinds. The neurotic conditions 
accompanying certain varieties of hirsuties may be inappreciable ; or 
evidently be due to traumatism ; or be exhibited in paralyses, muscular 
atrophy, etc. 

Treatment. — To Hardaway, of St. Louis, Americans are indebted 
for the popularization of the method of removing superfluous hairs by 
electrolysis, first devised by Michel, of his city. Extensive pilary 
growths are now often removed by this method without subsequent 
reproduction of the hairs. A fine needle is introduced into the hair- 
follicle and gently passed down to the papilla at its base. This instru- 
ment is connected with the negative pole of a galvanic battery contain- 
ing six or more elements, the positive pole of which is in connection 
with a sponge-electrode held in the patient's hand, who is thus enabled 
to make or break the circuit at will. When the current is passed a 
few minute bubbles of gas escape from the orifice of the follicle, and 
when the hair-papilla is destroyed the hair itself is readily extracted. 
The dexterity acquired by practice is requisite for the proper perform- 
ance of the operation, with a view particularly to the insertion of the 
needle at the proper angle into the follicle. Few patients complain of 
pain. The number of hairs removed at a sitting varies with the sensi- 
tiveness of the patient's skin. The resulting scar is quite imperceptible 
or far less disfiguring than the hirsuties, suggesting the appearance of 
the male beard after shaving. Transitory macules, papules, pustules, 
and wheals occur at the site of puncture. Care should be taken not to 

'Brit, Med, Jour., January 26, 1884, p. 160, 



HYPERTRICHOSIS. 483 

insert the needle too deeply in the particularly vascular regions of the 
face, as an aneurysmal tumor might be produced as a consequence. 

Every detail of this exceedingly simple operation has now been 
carefully studied by American operators, and the results, as confirmed 
by our experience, may be given as follows : 

1. Any good galvanic battery may be employed. We use habitu- 
ally a forty-cell stationary battery, the switchboard of w T hich is so 
arranged that any number of selected cells may be brought into the 
circuit. A galvanometer should be placed in the circuit indicating a 
current of from one-half to four milliamperes. The number of cells 
employed should vary with different individuals, different parts of the 
face, and on different days with the same individual — e. g., a smaller 
number is required when a patient previously operated upon returns 
after a somewhat long period of rest. Two to four cells only may be 
tolerated over the tip of the nose or the upper lip near the septum nasi. 
Twelve to twenty may be well borne, after some experimenting, on an 
insensitive chin. 

2. The best needle is a carefully selected, fine jeweller's broach, its 
shaft and point being annealed by rapid passage through the flame of 
an alcohol lamp. It is often useful to have the point also well rounded 
on an emery-wheel. Irido-platinum needles are useful, but inferior 
for general work to a broach. 

3. The needle-holder should be simply a convenient insulated 
handle, sufficiently long to protect all the points of the operator's right 
hand from the current, and should be as light as possible, since a 
heavy holder interferes with delicacy of touch. Duhring's * holder, 
which is of the shape of a thin lead-pencil or pen-holder, is about four 
inches in length. The handle, or stem, is of hard rubber, through 
which passes a metallic rod, acting as a conductor for transmission 
of the current. The needle is inserted into the needle-holder proper, 
which is slotted, the needle being clamped immovably by means of a 
screw-nut. In the other end of the stem is an insulated inserting-pin 
attached to the cord leading to the battery. The instrument is con- 
venient to handle and altogether well adapted to the operation. 

4. The patient should be seated or reclining at ease in a good light, 
with the handle of the electrode connected with the positive pole of the 
battery in one hand, ready to press the sponge into the palm of the 
other. In this way, at the bidding of the operator, the patient makes 
and breaks the circuit at will. The sponge attached to the holder 
should be wet with a solution of salt and water. 

5. As to further details of the operation, it is well (a) to make and 
break the connection only when the needle is in situ, as this diminishes 
the pain of the operation ; (6) to introduce the needle with a gentle ma- 
nipulation (acquired only by skill and well characterized by Hard- 
away as a " catheterization " of the hair-follicle), observing a certain 
degree of parallelism with the hair-shaft as the needle enters ; (c) to 
operate leisurely, making sure that the current is not broken by sep- 
aration of the hands of the patient before the hair is completely free 
in the follicle. This last can be ascertained by gentle traction on the 

1 Amer. Jour. Med. Sci., July, 1881. 



484 HYPERTROPHIES. 

shaft in from twenty to forty seconds after insertion of the needle ; 
(d) to operate in succession upon contiguous hairs Avhen practicable, not 
selecting one here and one there, the latter course being productive of 
greater pain ; (e) never to use the positive pole in connection with the 
needle, an error which results in the production of unsightly pigmented 
blemishes on the surface of the skin. 

The previous employment of preparations of cocaine both hypoder- 
matically and by inunction — e. g., cocaine oleate — to relieve or diminish 
the pain of the operation, may be followed by exceedingly unpleasant 
consequences. A dermatitis thus induced may persist for months. 

Prince, of Boston, 1 lays stress upon the accurate regulation of the 
current by the aid of the absolute galvanometer, which we have found 
in practice useful but not essential. Fox, 2 of New York, reports a 
gradual decrease in the number of hairs returning after operation, 
proportioned to the improvement in the instruments and the skill 
of the operator. The percentage of such returns varies with these 
conditions. 

All patients affected with hirsuties are not to be advised the opera- 
tion. We have declined to operate in many cases which were not 
deemed to belong to the class in which the best results of the operation 
may be expected. Young and vigorous women, usually unmarried, 
may point out hairs to be removed that are merely full-developed fila- 
ments of a thick downy growth, all the hairs of which are rapidly 
pushing to equal maturity. Here the operation itself, by inducing 
hyperemia of the skin, may simply hasten the hypertrichosis actually 
in progress, and thus aggravate the disorder. In most cases, when an 
operation is undertaken, both parties should fully understand the possi- 
ble issue. It is a question whether it lies within the legitimate sphere 
of the physician to remove superfluous hairs from the habitually covered 
breasts and arms of women. 

This operation has unfortunately found its way into the hands of 
the unprincipled and the ignorant, who, in their efforts to extract 
money from the credulous, have in some of the larger cities brought 
electrolysis for hypertrichosis into ill repute. The operation is, how- 
ever, all that can be desired if only it be performed with sufficient 
skill and conscientiousness ; but if hairs are rapidly plucked away from 
their follicles while an electric current is passing merely, the return 
of each filament is prompt and mortifying to the patient. It should, 
therefore, be understood as a procedure requiring ample time on the 
part of the operator, and either fairly good vision or eyes aided by a 
mounted lens. Not more than from forty to sixty hairs can be re- 
moved in an hour by an expert operator ; and there are few who can 
work with advantage more than one hour at a sitting, or more than one 
or at most two hours in a day. 

Hairy nsevi may be removed by complete excision, but removal of 
the hairs by electrolysis will sometimes result in disappearance of the 
entire growth without such operation. 

1 The Exact Measurement of the Electric Current, and other Practical Points in 
the Destruction of Hair by Electrolysis. 

2 The Use of Electricity in the Kemoval of Superfluous Hair, etc. Detroit, 1886. 



HYPERTRICHOSIS. 485 

Freund, 1 Wood, 2 and others report removal of hair with the a>ray. 
From six to twenty-four exposures are necessary, and in the majority 
of cases the hair eventually returns. In a few instances the result has 
apparently been permanent. By the careful and skilful use of brief 
exposures dermatitis and other unfavorable results may be avoided. 

Depilatories for the removal of superfluous hairs operate by the de- 
struction of the filament without obliteration of the papilla. The con- 
sequence is that the hairs are reproduced in the course of about a fort- 
night. Most of the compounds used for this purpose contain either 
calcium sulphate, arsenic sulphate, or barium sulphide, made into a 
paste with warm water. This paste is applied over the hairy surface 
with a spatula, and is permitted to remain until it dries, or produces a 
sensation of heat or burning, a period usually requiring ten minutes. 
It is then rapidly removed by scraping with a spatula, and the surface 
thoroughly cleansed with warm water, after which the skin is anointed 
with cold-cream salve or other similar unguent. 

Of these depilatories Duhring recommends the following : 

R Barii sulphidi, 3ij ,* 8 

Pulv. oxid. zinc.,"! ___... --10 

Fmv. amyl., J J ' M. 

To be prepared in form of an impalpable powder, which, just before 
using, is to be mixed with water to form a thin paste. 

The following are formulae devised by French authors : 

R Sodii hydrosulphit, 3iij ; 12 

Calcis, ) -- _ -- .a 

Amyli pulv., J aa S *l aa 40 M. 

To be finely triturated, and, when used, to be made in a thin paste 
with water. (Boudet.) 



R Calcis, 5j ; 4 

Sodii carbon., 3jss ; 6 

Cerat. adipis, ^j ; 30 

To be applied as a depilatory in the manner of a paste. 



M. 



All these formulae require caution in their use, and they should 
rarely be intrusted to patients themselves. 

Shaving may be practised upon the hirsute face of women, and, 
with a similar end in view, also epilation ; the latter, particularly in 
cases of hypertrophy of the hair limited in extent. Partial success 
has attended the thrusting into the follicles of needles previously 

[dipped in caustic solutions, or heated in various degrees, but these 
methods are inferior to electrolytic destruction of the hair-papillae. 
The hairs may be rendered less conspicuous by bleaching them with 
frequent applications of hydrogen peroxide. Bulkley 3 states that a 
thorough use of this remedy retards the growth of fine hairs. 

x Wien. klin. Woch., September 23, 1899. 

2 Lancet, January 27, 1900. 

3 Jour. Amer. Med. Assoc, December, 1899. 



486 HYPERTROPHIES. 

(EDEMA NEONATORUM. 

(Edema of the newborn is characterized by the occurrence of an 
indurated tumefaction of the skin, most noticeable in the lower ex- 
tremities of infants affected with impaired circulation. 

(Edema and sclerema of the newborn have long been confused. The 
distinction between them was first well established in 1877, when Par- 
rot, under the title Athrepsie, first described with clearness the 
morbid condition now recognized as oedema neonatorum. 

Symptoms. — The disease, which is of exceedingly rare occurrence 
in America, is observed in infants prematurely brought into the world 
or at term, and of feeble vitality. Between the first and the third day 
after birth the child is found to be drowsy and difficult to waken, with 
the posterior and other parts of the thighs and legs, the hands, and 
the genital organs pallid, cold, livid, and retaining the impress of the 
finger as do oedematous tissues in general. At this point recovery may 
ensue, but in severe cases the oedema spreads, always more markedly in 
the lower portions of the body, and the skin becomes violaceous red, deep 
yellowish, or dirty looking. As the disease advances the integument 
becomes more and more difficult of indentation. Meanwhile the little 
patient becomes more drowsy, its respirations fewer, its cry weaker, 
and its temperature lower. Death may ensue from a pulmonary com- 
plication, from diarrhoea, or from any intercurrent disorder. Usually 
the child passes into a state of coma. When recovery ensues the oedema 
becomes less marked and the indurated skin more and more impressi- 
ble. A few days, in satisfactorily managed cases, suffice to restore the 
patient to a condition of health. In some instances the oedema begins 
in other portions of the body than those named ; and in cases there is a 
marked febrile reaction. 

Etiology. — The recognized causes of the malady are prematurity 
of delivery, exposure to severe cold soon after birth, poor hygiene, 
atelectasis of the lungs, and inability to take the nipple. Blacker, 1 
describes a case, seemingly typical, in which there was no evident 
etiology. The child at five weeks was perfectly well and properly nour- 
ished, but still retained the hard oedema of the buttocks, thighs, part 
of the arms, and chest. The mother was always well, and the preg- 
nancy, labor, and puerperium presented no unusual features. 

Pathology. — All cases show an effusion of yellow serum into the 
subcutaneous tissue, possibly in consequence of the enfeebled action of 
the heart, and the fat on excision is found to be particularly dense 
and yellowish. Enlarged liver, pulmonary congestion, venous throm- 
bosis, and nephritis have been recognized in a small number of cases. 

Diagnosis. — The distinction between oedema and sclerema neona- 
torum is not made without difficulty, the disorders greatly resembling 
each other. In sclerema the joints, and particularly the jaws, are 
immobile ; the disease is likely to be generalized ; the firmness of the 
integument is greater ; and there is no tendency to an oedema chiefly 
marked in dependent parts of the body, as over the lower limbs. 
The color of the skin in the two disorders may be nearly the same. 

1 Brit. Jour, of Derm., 1898, vol. x., p. 87. 



SCLEREMA NEONATORUM. 48? 

The pitting on pressure of the swollen skin is highly characteristic of 
oedema neonatorum. Scleroderma does not occur in children before 
the close of the first year. 

The Prognosis is grave ; but with proper treatment recovery may 
occur when the oedema is not generalized. 

The Treatment is that of scleroderma neonatorum. 

SCLEREMA NEONATORUM. 

(Gr. GK?i7fp6c } hard; v£ov f new; yevvau, to bring forth.) 

(Scleroderma Neonatorum. Fr., Sclereme des Nouveau-nes.) 

This disease is not to be confused with oedema neonatorum, from 
which it is wholly distinct. 

Symptoms. — At birth, or between the second and the tenth day 
after, the lower limbs of the child assume a livid or whitish-yellow 
appearance, occasionally suggesting the hue of wax ; and they become 
of a leathery consistency. This condition spreads gradually over the 
lumbar region, the dorsum of the body, and the chest in front and 
behind, and in the course of a few days may involve the entire in- 
tegument. When pressed upon with the finger the skin produces the 
impression of half-frozen tissue ; the face suggests a cold and rigid 
mask ; the thighs in their sockets and the arms in the shoulder-joints 
are immobile. Usually there is somewhat less firmness of the abdom- 
inal integument. The taking of the nipple, deglutition, and even the 
opening of the oral orifice are effected only with great difficulty, 
and eventually become impossible. The respirations are shallow and 
imperceptible ; the pulse in well-marked cases is imperceptible at the 
wrist ; and the thermometer in the rectum is not raised to the lowest 
register of the ordinary clinical instrument. There is often no cry. 

There may be a coincident icterus ; and often sprue has been observed 
in the mouth before the declaration of well-marked symptoms. The 
congenital patients are often stillborn. The majority of subjects of the 
disease perish before the ninth day. 

Etiology. — The immediate cause of the malady is retardation of the 
circulation in the cutaneous capillaries, and this may depend upon prior 
disease (pleuro-pneumonia, intestinal disorders) or upon conditions oper- 
ating before or at birth (congenital anomalies of lymphatics, syphilis, 
feeble vitality). 

Pathology. — Ballantyne has observed a small-cell growth in the 
corium, of perivascular situation ; Langer ascribes the condition to ex- 
cess of fatty acids in infants as compared with adults, with the result of 
f producing a fat consolidation. In JNTorthrop's cases 1 no fluid escaped 
on section of the tissues, which were as semisolid as if frozen ; scattered 
hemorrhages involved the alveoli, connective tissue, and lymph-spaces 
of the lungs, but there was no collapse. According to Ballantyne, the 
disease is due to overgrowth of connective tissue leading to atrophy of 
the fat-cells and is dependent upon a trophoneurosis. Parrot recognized 

1 Arch, of Peediat,, 1890, vol. vii. 



488 HYPERTROPHIES. 

the fact that the connective-tissue trabecule were more numerous and 
thicker than in other cases. 

The Treatment of both oedema and sclerema neonatorum is by ele- 
vating the body-temperature (in an incubator, wrapping the entire body 
in wool, warm water-baths, etc.), and by improving the nutrition in 
every possible way (sterilized milk and stimulants by the stomach- 
pump, through nose or pharynx). The body may also be well rubbed 
with warmed oil or camphorated alcohol. Brocq suggests friction with 
the warm hand from below upward. 

SCLERODERMA. 

(Gr. GKkrjpoQ, hard ; depjua, the skin.) 

(Hide-bound Skin, Dermatosclerosis, Chorionitis, Scleriasis, 
Sclerema Adultorum. Ger., Hautsclerem; Ft., Sclero- 

DERMIE.) 

Symptoms. — [A] Diffuse Symmetrical Scleroderma. — The skin- 
symptoms of the disease may be preceded by prodromic pains of a 
rheumatismal character, or by singular cutaneous sensations (pricking, 
tingling, formication), or by muscular cramps, and neurotic sensations. 
In some instances, also, there are vesicles, blebs, scales, local hyperi- 
droses, or losses of sensibility in the skin which is about to become the 
seat of the disorder. 

With and without these prodromic features the skin and subcutane- 
ous tissue, chiefly of the upper portion of the body, become symmet- 
rically involved either in a gradually increasing induration or in an 
obscurely defined oedema of a firm character which at first pits under 
strong pressure with the finger, but later becomes as indurated and tense 
as hard leather. The integument is usually exceedingly difficult to 
pick up between the finger and thumb, and is shining, smooth, waxy, 
or of alabaster-like hue ; in other cases it is of a dirty-yellowish, grayish 
shade. This is the stage of infiltration, and when pronounced it is not 
to be mistaken for any other condition. The face may be, both to the 
eye and the finger, mask-like, immobile in features, and expressionless. 
The lips are then stiffened and opened with difficulty ; the eyelids are 
similarly but much less severely involved. The back of the neck may 
be firm ; the chest, shoulders, and arms may be either immobile or 
movable with difficulty ; the ribs are often bound down so firmly by 
the cuirass of leathery integument that respiration may be impeded 
seriously. The temperature is not changed, and sweat may or may not 
be exuded over the affected areas. The abdominal surface is relatively 
spared. This condition may come on insidiously, and may require 
years for its complete evolution ; at other times the progress is rapid 
and the evolution is even subacute in type. Often the upper extremities 
are so involved that the fingers resemble curved talons ; the wrists lose 
their flexibility, the forearms their usefulness. So extreme is the help- 
lessness of some patients that they require to be dressed, washed, and 
fed, even when able to travel with relative comfort. 






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SCLERODERMA. 489 

The lesions are accompanied at times by other subacute disorders, 
such as subcutaneous tubercles, eczema, erysipelas, canities, anidrosis, 
zoster, and acne. 

In the later or atrophic stage of the affection the cedematous or 
infiltrated areas undergo induration and contracture. The skin becomes 
then more and more tightly stretched and thinned over the underlying 
structures, and it is no longer possible after drawing the finger over the 
surface to produce a yellowish- white tracing of its route that disappears 
as the circulation slowly returns along the line. When this extreme is 
reached the atrophic skin becomes dry, scaling, fissured, or even ulcer- 
ated ; the muscles may waste considerably, thus reducing a limb several 
inches in circumference; the teeth may fall; the fingers permanently 
be flexed into the palm or the forearm on the arm. When the condi- 
tion becomes to this extent grave, the patient, who before seemed to 
enjoy a fair degree of health, suddenly experiences rheumatoid pains 
and neuralgias, or exhibits other signs of constitutional impairment; 
and intercurrent visceral disorders gradually bring on a marasmus 
which in some of the reported cases has ended fatally with renal, 
cardiac, or pulmonary symptoms. 

[B] Circumscribed Scleroderma; Morphcea (Gr. /iop(fiyj, a blotch); 
Keloid (of Addison). — Circumscribed scleroderma, or morphcea, is 
characterized by the occurrence of one or of several discrete, well- 
defined, firm, and smooth points, patches, lines, or bands, that are often 
slightly elevated or depressed, and surrounded by a delicate violaceous 
or lilac-tinted halo, the involution of which may be followed by macular, 
punctate, or striate atrophy of the skin. 

This form of scleroderma was once held to be rare. It is, however, 
more commonly under observation than is usually believed. French 
authors distinguish between the variety displayed in plaques and that 
occurring in bands. Some forms of the latter variety are better 
described as linese atrophica?. 

The patches of morphcea commonly begin as rosy or violaceous 
macules, which irregularly extend in area from nail-sized to larger 
patches, either with relative rapidity or with slowness. In a variable 
period of time the centre of each patch becomes whitish, while the 
peripheral portions of the plaque retain their peculiar shade of color. 
There is thus formed a roundish or oval or irregularly outlined 
area, rarely larger than a dinner-plate, with a central portion some- 
what elevated, infiltrated and "lardaceous" or flattish, and near the 
level of the adjacent skin. The blanched centre has often the hue of 
old ivory; later, this may be commingled irregularly with a flattened 
streak or band, distinguished with difficulty from scar-tissue. These 
patches may be single or multiple; in the latter event they are 
arranged, as a rule, along the line of distribution of the cutaneous 
nerves of the trunk, along the inner faces of the thigh, more often on 
the lower than over the upper extremities, and asymmetrical in most 
cases. When the tissue is pinched between the thumb and finger it at 
first gives the impression of stiffness and hardness ; in the later stages 
of the disease the skin may be so atrophied over the region involved 
that it is impossible to make this test. The surface is dry and smooth, 



490 HYPERTROPHIES. 

or, when very carefully inspected, is seen to be traversed by exceed- 
ingly delicate lines. In some instances the plaque is dotted regularly 
with depressed points resembling the patulous orifices of sebaceous 
glands of the face in certain cases of acne, the slightly discolored, 
minute, funnel-shaped orifices contrasting thus with the dead-white 
hue of the patch. In other cases this appearance of dotting or picking 
out of the surface is more conspicuous at one part than another, being, 
for example, well shown at an advancing border, with a dead -white, 
depressed centre, or at both extremities of a long oval. 

The border of typical patches is characteristic. It is made up usu- 
ally of a narrow zone having a pinkish, lilac-tinted, or violaceous hue, 
which, when closely viewed, is seen to be constituted of a plexus of 
fine vessels. The zone may be wanting wholly, as is well shown in 
some cases in which the temple is involved ; the border further may 
be present in such degree as to be fully as conspicuous as the whitish 
central area. In a patient presenting a palm-sized patch over the 
sacrum, together with a few multiple spots on the side of the neck (a 
portrait of the same having beeu made in oil), the flame-like, violet- 
shaded areola extended for several, inches on one side away from the 
disk, and one of the larger vessels of which it was constituted could be 
seen at a distance of several feet from the patient. Purplish, and 
even blackish, hues have at times been recognized in the halo by other 
observers. 

As a rule, there are few subjective phenomena ; in some cases itch- 
ing, tingling, pricking, and other sensations are experienced. The 
variations observed in this affection are as numerous as they are strik- 
ing. The disease may be extensive or be limited to one or a few very 
small spots. The names : maculosa, nigra, lard ace a, alba, 
plana, atrophica, etc., are merely descriptive of clinical features, 
and are becoming obsolete. 

Between the several types of scleroderma noted above are to be 
found instances which it is difficult to assign to the one class or 
the other. Some are mixed forms in which diffuse scleroderma is de- 
veloped in one part of the body and a circumscribed form in another ; 
in other cases numerous morphoea plaques are distributed symmetrically 
over the body or develop a generalized symmetrical scleroderma. As 
a rule, the symmetrical forms occur most extensively over the upper 
part of the body ; while the more frequent unilateral plaques of mor- 
phoea affect in greater proportion the lower limbs. Often the symp- 
toms of the disease resemble at the outset those described as character- 
istic of oedema neonatorum, with pitting of an oedematous surface under 
pressure. Great variation has been noted as regards the presence, 
absence, or increase of sensibility. Sweat and sebum may or may not 
be secreted from the affected patches. 

In the generalized forms, whether symmetrical or not, there may 
occur serious complications from visceral disease (cardiac, vascular, or 
renal) due in part to interference with the function of large areas of 
the skin. Arthritis is not infrequently a concurrent disorder. In 
some cases the mucous' surfaces are involved. In other cases there are 



SCLERODERMA. 491 

organic changes in the viscera as well as sympathetic disturbances 
of function. Some of the visceral muscles have been recognized as 
involved in scleroderma. 

According to Besnier and Doyon, pigmentation is one of the most 
important of sclerodermatous symptoms. Beside the pigmented dots 
visible over the sclerosed patches, there often exists a species of chlo- 
asma in the form of bronzing, diffuse or in irregular islets, over the 
neck, shoulders, and elsewhere. These pigmentations are often inter- 
spersed with whitish patches of vitiligo. 

The course of circumscribed scleroderma is either chronic, lasting for 
from one to ten years or more ; or subacute, with evolution accomplished 
in a few days and an almost equally rapid involution ; or atrophy of 
skin, subcutaneous tissue, and muscle may slowly or rapidly follow, 
and result in the production of attachments to periosteum or in de- 
formity due to contracture. Ulceration may ensue, and in a few in- 
stances has occurred early in the disease. Atrophy of bone is an 
exceptional result. In yet other cases absorption of the material con- 
stituting the plaque is effected without sequels of any sort, few, if any, 
traces of the process remaining. 

The band-form of circumscribed scleroderma usually occurs in 
ribbon-shaped elongations stretching along a limb in its longitudinal 
axis, or over one-half of the face. Most of these cases are distin- 
guished by the occurrence of either an elevated ridge or furrow, or 
(what is not very rare) an elevated ridge with a furrow on one side. 
The median line of the forehead is the commoner site of this anomaly 
on the face ; over the trunk it is best displayed on the breast. As 
noted above, some of the cases collated in this category are instances 
of linese atrophicas. ' 

Finlayson 1 observed in one case of scleroderma symmetrical gan- 
grene of the extremities, a complication related doubtless to the " sym- 
metrical asphyxia of the extremities " described by a number of English 
authors. The so-called " glossy fingers " and " sclerodactylie " of 
symmetrical distribution may belong to the same category. 

Hemiateophia Facialis. — Severe grades of the disease are noted 
by several authors, in which to a varying extent, the surface of the lateral 
half of the face has been involved. Here not only the subcutaneous 
i tissue, but also the aponeuroses, periosteum, and bones may partici- 
pate in the atrophy, a fact well illustrated in the case of Robinson's 
I patient. 2 In this instance there was also a distinct sclerodermatous 
; lesion on the face of one thigh. 

Etiology. — About three-fourths of all cases occur in women. The 
j young and middle-aged are generally the victims of the disorder, though 
cases are reported between the first year of life and advanced age. 
The predisposing causes of the affection are : rheumatism and the 
climatic changes to which rheumatism is most often attributed; all 
neurotic states due to emotional influences, grief, anxiety, etc.; trau- 
! matisms by friction, blows, and direct injuries of nerves ; blisters ; 

1 Med. Chronicle, January, 1886. 

2 Amer. Jour. Med. Sci., October, 1878. 



492 HYPERTROPHIES. 

exposures to the direct action of the sun ; and obscure disturbances 
of the nervous centre that are difficult to appreciate. In one case, a 
young woman with a series of circumscribed patches along the inner 
face of the right thigh, could scarcely endure the fatigue of exposure 
of the part while an oil painting was made of the disks.; another case 
was that of a muscular blacksmith, who exhibited a large plaque of 
morphcea over the trunk. 

The etiological importance of the nervous system is too obvious to 
require demonstration. This fact is much more distinct in the local- 
ized manifestations of the disorder, in which a region supplied by 
a single nerve or traversed by a nervous trunk is solely involved. 
Harley, Schwimmer, and others have recognized cardiac and gastric 
disturbances ; Westphal and Eulenberg, central and peripheral changes 
in the nervous system ; Heller demonstrated in one case closure of the 
thoracic duct. Bancroft l repeatedly recognized filarise in large num- 
bers in the blood of a young girl in Australia who was affected with a 
characteristic scleroderma. Atrophy and other changes in the thyroid 
gland have been noted by Hektoen, 2 James, 3 Uhlenhuth, 4 and others. 

Pathology. — The confusion which has existed in relation to the ques- 
tion of the identity of scleroderma and morphcea is due .to various 
causes. By several authors similar symptoms are described under each 
of the two names ; and the symptoms described as peculiar to each are 
occasionally seen either simultaneously or successively in the same 
individual. 

Microscopical examination of the structures involved in the disease 
has proved unsatisfactory. The connective tissue of the skin has been 
found, according to Kaposi, indurated and thickened ; its elastic fibres 
multiplied at the expense of the panniculus adiposus ; its muscular 
tissue hypertrophied ; the pigment in the rete and corium increased ; 
the sweat-glands dilated ; the lumen of the blood-vessels diminished, 
and their walls ensheathed in accumulations of what he terms " lym- 
phatic cells." 

The nature of the pathological process in scleroderma is unknown ; 
no characteristic changes in the nervous centres have yet been appreci- 
ated. In the generalized form the two vascular systems, the sanguine 
and the lymphatic, exhibit within and about the walls of vessels embry- 
onic cells which become converted into fibro-plastic bodies. This 
change produces in parts an increase in the tunica media until it is 
twice its normal thickness. The lumen of the Vessels is thus obstructed 
and at times obliterated, indicating that the essential process is an 
endarteritis obliterans, inducing, in the areas to which each twig of 
vessels is distributed, an exsanguinated state with a surrounding 
hyperemia. The latter accounts for the peripheral halo of the circum- 
scribed forms of the malady. That there is at the same time lymphatic 
obstruction is clear, with, either from the one cause or the other, an 
overproduction of connective tissue and elastic fibres in the areas of 

1 Lancet, February 28, 1886, p. 380. 

2 Centralbl. f. allgem. Path. u. path. Anat., 1897, Bd. viii., S. 673. 

3 Scottish Med. and Surg. Jour., Mav, 1899. 

4 Berlin. klin/Woch., 1899, No. 10.' 



SCLERODERMA. 493 

involvement. The corium is commonly hypertrophied, at least in the 
papillary layer ; while the subcutaneous tissue and panniculus adiposus 
are proportionately thinned ; and even at times, as suggested by the 
clinical features noted above, may wholly disappear. The pigment 
commonly vanishes from the prickle-layer ; the coil-glands at first are 
dilated, and later may disappear when the atrophic stage is reached. 
In the late circumscribed forms the papillae of the corium may also fall 
into atrophy* and the superior vascular plexus of the corium may 
undergo obliteration by thrombosis (Crocker). The compression of 
both glands and vessels is supposed to account for the final sclerotic and 
cicatriform condition of the advanced cases. 

Diagnosis. — In vitiligo there is an entire absence of all structural 
cutaneous changes and the skin has a characteristic milky-white color, 
the hairs of the part being also blanched. Both the pigmented 
macules and atrophic patches of lepra are remarkable for their anaes- 
thetic condition, and their coincidence with, or sequence from, other 
readily recognized symptoms of the disease, such as tubercles, bullae, 
ulcers, and involvement of the hairs, nails, eyes, and other organs. 

In sclerema and oedema neonatorum the age of the patient would 
serve to distinguish the disorders from scleroderma. In cancer en 
cuirasse (papillary cutaneous carcinoma), chiefly of the skin of the 
breast in women, but encountered elsewhere, the resemblance to 
scleroderma is striking ; and eminent surgeons have confounded the 
two. In both affections the skin, especially that of the thorax, is 
converted into a dense leathery cuirass, but the distinction is made as 
follows : first, the carcinomatous condition of the skin may be secondary 
to a cancerous change in the breast or nipple, in which case the doubt 
is readily removed ; second, if primary, the firm, isolated, and deeply 
tinted nodules of cancer are readily distinguished, projecting from the 
dense peripheral cutaneous infiltration ; third, the oedema and lymph- 
angitis associated with cancerous involvement are most often unilat- 
eral, and are limited very distinctly to the arm on the side of the body 
most seriously involved ; fourth, the line of demarcation of the can- 
cerous change, while indeterminate on one side, is usually at the edge 
of advance distinguishable by tongue-like erythematous prolongations 
of a dull-reddish hue ; lastly, the tendency to ulceration, the coincident 
and resulting cachexia, the possible axillary adenopathy, and the rela- 
tively rapid and fatal result in cases at all liable to be confused with 
scleroderma, point severally to the truth. 

In ichthyosis the congenital history, the presence of ichthyotic 
plates over the affected surface, and the general conservation of the 
health of the patient suffice to identify the disease. 

In progressive lenticular melanoderma (angioma pigmentosum et 
i atrophicum) the melanotic condition of the skin, in connection with 
warts, tumors, ulcers, and limitations of the disease to the exposed 
parts, suffice to distinguish its character. 

Treatment. — In the management of symmetrical or generalized 
scleroderma the influence of climate should be considered. More im- 
provement is secured for these patients after removal to a dry equable 
climate than can be obtained elsewhere. If they must remain under 



494 HYPERTROPHIES. 

unfavorable climatic influences, the body should be well protected by 
woollen, over muslin, silk, lisle-thread, or balbriggan undergarments; 
and while an outdoor life is desirable, such exposure should always be 
avoided in unfavorable weather. Internally cod-liver oil, the ferru- 
ginous tonics, and the nutrients generally are often indicated, as well as 
a roborant and generous diet. Thyroid extract has given good results 
in a small percentage of the cases in which it has been tried. Phillip- 
son 1 reports relief of severe diffuse scleroderma by the internal adminis- 
tration of salol in doses of from 2 to 3 grammes daily. Hebra 2 reports 
good results in three cases from intramuscular injections every second day 
of 10 minims of a 15 per cent, alcoholic solution of thiosinamin. The 
employment of potassium iodide, arsenic, mercury, and other remedies, 
such as lithium benzoate, sodic bicarbonate and salicylate, and the alka- 
lies, supposed to be indicated by the rheumatoid symptoms, have been 
alike praised and condemned by men of eminence on both sides of the 
Atlantic. Remedies of the reconstituent order should always first be 
employed and no resort be had to others save in emergency. 

The local treatment is by baths, massage, galvanism, alternate hot 
and cold douches or the actual cautery over the spinal column. Fol- 
lowing the daily salt-and- water or alkaline bath of a temperature suited 
to the season of the year and 'the physical condition of the patient, 
inunctions with cod-liver oil, lanolin, lard, or vaselin, neat's-foot oil 
slightly scented, or other simple oil or ointment, may be used. To 
these may be added with advantage in many cases 2 to 10 per cent, of 
the oleate of mercury or of ammoniated mercury. In morphoea Brocq 
employs electrolytic puncture as in the treatment of hypertrichosis. 
Mercurial plasters are applied in the intervals of each sitting. 

Prognosis. — Symmetrical diffuse scleroderma, well treated in young 
subjects, usually results favorably without impairment of the general 
health. When atrophic changes occur the skin may recover its supple- 
ness and pliability, but this cannot be counted upon. Deformity may 
in either event complicate an otherwise favorable issue. In a small 
proportion of cases the disease becomes so extensive and severe as to 
produce a fatal marasmus ; more frequently death results from inter- 
current disorders. 

In circumscribed patches (morphoea) the majority recover without 
serious consequences; the few go on to sclerosis of subcutaneous 
structures and consequent deformity. In the most of the simpler 
cases the disease from first to last seems to have but a local significance. 

ELEPHANTIASIS. 

(Gr. e?J<f>ag } elephant.) 

(Elephantiasis Arabum, Pachydermia, Bucnemia Tropica, 
Elephant Leg, Barbadoes Leg.) 

Under this title has been included a group of affections differing 
both as to their essential cause and nature. On the one hand are to 

x Deutsch. med. Woch., 1897, 33. 

2 Arch./. Derm. n. Syph., 1899, vol. xlviii., No. 1. 



PLATE XIII. 




Elephantiasis Telangiectodes of the Upper Lip and Portions 

of the Face. 



ELEPHANTIASIS. 495 

be recognized those disorders due to obstructive embarrassment, simple 
or even mechanical in character, of either the venous or the lymphatic 
circulation ; and, on the other hand, obstructive embarrassment due to 
the presence in the vessels of a parasite, the filar ia sanguinis hominis. 
The symptoms of the two disorders are for the present considered 
together. 

Symptoms. — The disease is more common in the tropics, where it is 
usually of parasitic origin ; but sporadic cases are of occurrence in all 
countries, and are not very rare in portions of the United States. The 
most frequent seat of elephantiasis is the lower extremity of one side, 
where the foot, the leg (Fig. 59), or also the thigh of the same limb, 
may enlarge. The penis and scrotum of men (Fig. 60), the labia and 
clitoris of women, the upper extremities, the face, the ear, and portions 
of the trunk may likewise become involved. 

The disease is insidious in its approach, and remarkably chronic in 
its career. Usually, localized inflammations precede, as an erysipelas 
or a dermatitis, with or without involvement of the lymphatic vessels 
and glands. At the same time there is a condition of general fever, to 
which succeeds a defervescence, with abatement of the local inflamma- 
tion, its sequels becoming manifested in a more or less persistent 
oedema of the part lately inflamed. After intervals of days, weeks, or 
months the pyrexia recurs with still greater involvement of the swollen 
tissues, which, with each access of fever, increase in volume and gain in 
density. When the elephantiasic condition is fully developed the skin 
is tense, glossy, and blanched or discolored in various shades. Pressure 
upon the cedematous part is followed by pitting, but the tissue beneath 
is felt to be brawny and indurated. The parts beneath the skin are 
perceptibly increased in volume, especially the subcutaneous tissue ; and 
the circumference of a limb thus diseased may be several times larger 
than that of its fellow. A lymphangitis is usually declared by painful, 
cord-like, linear indurations of the part, associated with adenopathy of 
the nearest ganglia. In older cases the skin loses its glabrous aspect, 
and exhibits eczematous, verrucous, papillomatous, seborrhceie, and even 
ichthyotic changes. Pigmentation, even to a blackish tint, may ensue ; 
scaling, Assuring, and furrowing are common ; and the accumulation 
of altered sweat and sebum in these depressions is the source of an of- 
fensive stench. During the course of the disease almost all the ele- 
mentary lesions of the skin may be displayed : macules, vesicles, pap- 
ules, tubercles, pustules, blebs, ulcers, crusts, scales, excoriations, and 
fissures. Warty growths form as large as those seen in ichthyosis hys- 
trix, and in some cases reddish-colored tumors spring from the hyper- 
trophied integument. 

When fully developed in the lower extremity the unwieldy limb, 
i with the foot, ankle, and leg massed into one huge, cumbrous cylinder, 
bears a striking resemblance to that of the elephant, from which cir- 
cumstance the malady first received its name among the Arabs. Loco- 
motion is then greatly impeded or is rendered impossible. Not less 
striking is the similar deformity of the genital labia of women or the 
scrotum of the male, the latter at times hanging far below the knees 
(Fig. 60). • 



496 



H YPERTROPHIES. 



The penis disappears in rugous folds, and the urine passes along 
a gutter formed of skin transformed 
into quasi-mucous membrane. As a FlG 60 

consequence of the fissures and ex- 
coriations which form the lymphatic 
channels are finally opened, and a 
true lymphorrhoea results. 

Fig. 59. 




Elephantiasis of the foot and leg. 



Elephantiasis scroti. 



Subjectively, the disease may be regarded as productive of less dis- 
comfort than would be suggested by its formidable features. Pain is 
experienced occasionally, and during the exacerbations accompanied by 
pyrexia there is corresponding malaise. The chief subjective sensations 
are those induced by weight and consequent tension, inseparable from 
the enormous masses of hypertrophied tissue. 

In elephantiasis of the scrotum there are frequently symptoms of 
irritation, both systemic and in the vicinity of the affected part (nausea, 
vomiting, inguinal pain, epididymitis, effusion into the sac of the tunica 
vaginalis, inflammatory swelling of the spermatic cord, and at times 
hernia). In some cases vascularization of the surface (telangiectatic 
elephantiasis) is a prominent feature. The form described below as 
Nsevoid elephantiasis may belong either to the same category, or to 
others in which there is lymphangiectasis (" lymph-tumors," " lymph- 
scrotum"), and these may be due either to lymphatic obstruction or 
to the parasite described later as of etiological importance in this 
connection. 

Lymph-scrotum (Varix Lymphaticus, Nevoid Elephantia- 
sis), fully described by Wong, Carter, Fayrer, Manson, 1 and other East 
Indian observers, is that condition in which the scrotum is more or less 
enlarged, and, though soft and silky to the touch, presents varying 
numbers of lymphatic varices, which on puncture or spontaneous rupture 
give exit to a rapidly coagulating lymph or chyle. Several ounces of 

1 Hirsch: Handbook of Geog. and Hist. J?ath., London, 1885, p. 328 ; and Tropical 
Diseases, London, 1900, second edition. 



ELEPHANTIASIS. 497 

this liquid may escape in an hour, and the discharge may continue to 
the point of exhausting the patient. The disease is produced solely by 
the filaria sanguinis hominis, 1 the embryo filarise being present in the 
lymph and in the blood. The inguinal and femoral glands are usually 
enlarged. As in elephantiasis of other organs, there may be occasional 
fever, chills, erysipelas, and other localized inflammations. Abscesses 
may occur, and in many cases the condition is followed by elephantiasis. 

Aceomegaly. — Cases of this rare form of elephantiasis are not 
infrequently reported. Typical instances of the malady have been 
made the subject of monographs (with illustrations of the facial and 
manual deformity) by Church, Hessert, 2 and Zeisler. There is sym- 
metrical enlargement of all the tissues, including bone. It is most 
common on the face and limbs. It is believed by many that the con- 
dition is dependent upon disease of the pituitary body. 

Cases of hypertrophy of one-half of the face are also to be assigned 
to the group of maladies to wdiich the name elephantiasis is applied, 
excluding the parasitic and lymphangiectatic varieties. Kiwall's patient, 
a girl eighteen years old, with a enlargement extending from brow to 
throat and involving the right side of the tongue as well as the bones 
and other soft parts, is an example of this anomaly. Crocker, Hebra 
and Kaposi, Barwell, and others report similar instances. One such, 
the subject of a skilful operation by Senn, suffered from a marked 
enlargement of one side of the face, due in part to an angiomatous and 
in part to a connective-tissue overgrowth. 

Etiology. — The causes of elephantiasis are different in the several 
disorders grouped under this title. AVucherer, Lewis, and Man son 
have demonstrated in cases prevalent in the East and West Indies, 
Egypt, Arabia, Abyssinia, Africa, Malabar, Barbadoes, Brazil, Mexico, 
and parts of China, the presence in the blood of the filaria sanguinis 
hominis. Embryos and filarial are found adhering to the walls of 
both lymphatic vessels and blood-vessels in elephantiasis of the tropics. 
Manson reports that in countries where elephantiasis is common the 
majority of the natives have filarise in their blood. The parent-worm 
lives in a large lymph-channel and produces young in immense num- 
bers which circulate in the blood. It is only when the parent-worm 
aborts and the ova or immature filarise are unable to pass through the 

i lymphatic glands that the circulation is obstructed. Thus it often 
happens that filarise are no longer found in the blood of an individual 

| who has developed elephantiasis. They are supposed to be introduced 

i through the medium of the mosquito. 

Other disturbances due to the same parasite, and only in part recog- 

\ nized as elephantiasic, are the lymph-scrotum described above, chylous 

j abscess, effusions, and vascular and hypertrophic enlargement of tissue 
and glands in and about tumors of the sort recognized as parasitic. 
In other cases different causes are to be recognized. Predisposition 

1 At the Third International Congress of Dermatology, held in London in 1896, 

i Manson exhibited living specimens of filaria moving in the blood-vessels under the 
microscope. 

2 Med. Kecord, May 6, 1893 (reprint). 

32 



498 HYPERTROPHIES. 

of races or individuals, heredity, climatic influences, malaria, fatiguing 
labor with the feet and legs immersed in water, and filth in connection 
with " misery," have all been cited as favoring conditions. To these 
causes should be added the local disorders especially common in the 
lower extremities that have in cases proved to be points of departure of 
elephantiasic hypertrophy, such as obstruction to the blood or lymphatic 
currents by pressure of tumors, pregnancy, or neoplasms ; ulcers, cica- 
trices, and traumatisms by pressure or friction ; cutaneous diseases ; 
systemic affections (syphilis, tuberculosis) ; and osseous disease. 

Pathology. — Even macroscopically the elephantiasic mass is seen to 
be built up of hypertrophic elements representing all the tissues of 
which the part is composed. The knife with difficulty divides the 
homogeneous, whitish, and lardaceous mass, from which on pressure 
exudes a fluid of similar color. The subcutaneous connective tissue is 
found relatively much more enlarged and sclerosed than the epidermis 
and derma ; though when section is made through the rugous and warty 
skin described above, all the elements of the papillary layer, rete, and 
stratum corneum are seen to participate in the changes described in 
connection with the pathology of verruca. Here and there are loculi 
filled with fluid lymph. The sheaths of the blood-vessels, lymphatics, 
nerves, and the bones, muscles, and aponeuroses are also thickened, 
solidified, and occasionally agglutinated, so as to be almost indistin- 
guishable in the mass of uniformly sclerosed tissue. The pigmentation 
of the derma is marked, the nuclei of the connective-tissue cells are 
multiplied, and the cutaneous glands intact, hypertrophied in their 
epithelial linings and investments, or, at a later stage, atrophied. 

It is evident that in many cases, as Virchow has pointed out, the 
earliest of the changes to be noted occur in the lymphatic glands and 
vessels, the whitish and yellowish lymphatic fluid which then accumu- 
lates in the tissue resulting from obstruction of the lymph-channels. 
In some of the remarkable cases on record the lymphatic obstruction 
is the prominent feature of the disease, and the elephantiasic enlarge- 
ment is subordinate in gravity to the former condition. Such are, for 
example, the noteworthy instances in which the lymph distends mul- 
tiple cutaneous vesicles, after rupture of one or more of which the fluid 
streams awav to a dangerous extent. 1 

Diagnosis. — The striking deformity which characterizes elephan- 
tiasis will always suffice for its recognition. In the earliest stages of 
the disease, when there is merely cedema or an erysipelatous or eczema- 
tous condition of the skin, it would be difficult, if not impossible, to 
decide as to the future of the disorder, especially in a locality in which 
only sporadic cases occur. A symmetrical hypertrophy of both legs 
and both feet, developing in America, even though described as " ele- 
phantiasis," should carefully be studied before a diagnosis is made of 
the particular disease here considered. The same might be said of 
elephantiasis of but one inferior extremity. A patient with an exten- 
sive deforming induration and enlargement of the right leg and foot,! 
accompanied by pigmentation and a well-marked warty condition of i 

*For a fuller description of this class of cases the reader is referred to Buse/s 
monographs on Occlusion and Dilatation of the Lymph- channels. 



I 



ELEPHANTIASIS. 499 

the skin, who had been pronounced the victim of idiopathic elephan- 
tiasis Arabum, had received a fracture of the upper third of both bones 
of the same leg during the previous year, and had since the accident 
constantly worn a tight bandage encircling the limb at the seat of the 
injury. The deformity rapidly disappeared under the application of a 
roller bandage extending from the toes upward. 

A peculiar and rare, though characteristic, deformity of the labia 
majora of women — most commonly the labium majus of one side — 
results from a tertiary syphilitic, gummatous infiltration which must 
be distinguished from elephantiasis. In cases of this kind the history 
of the patient and the relative inferiority as to bulk of the affected 
organ point to the nature of the disease. The syphilitic labium rarely 
exceeds the size of a large fist. 

A gigantic, hypertrophied mass of elephantiasic type is occasionally 
to be discovered in the lower extremity of only one side in patients who 
have been for many years the victims of an unrecognized and long- 
untreated syphilis. Even when the leg is many times its normal size 
and weight, and its contour lost in a thickened and roughened epidermis 
resembling the bark of a tree, the diagnosis may be made by discover- 
ing here and there in the depth of the mass circular and characteristic 
scars of healed gummatous ulcers. 

Treatment. — In the early stage of elephantiasis the febrile condi- 
tion of the patient and the localized cutaneous inflammation are to be 
treated by the measures appropriate for the relief of these conditions. 
Quinine, especially in malarial districts, is of the highest importance. 
When the elephantiasic development is established, if the genitals are 
involved the knife of the surgeon offers the best prospects. The result 
of such interference, both in the genitalia and the extremities, has in 
many cases been brilliant, though the mortality of such severe opera- 
tions is necessarily great. When the lower extremity is involved it 
should be maintained in a horizontal position, its ulcers if possible be 
healed, its excrescences removed, its circumscribed inflammations 
resolved, and then elastic compression be carefully and skilfully main- 
tained by means of a rubber bandage. The toes are first separately 
enveloped, then the foot and ankle, and lastly the leg. The results are 
sometimes highly satisfactory. 

Ligation and digital compression of the main artery supplying the 
elephantiasic leg have occasionally been followed by transient improve- 
ment. Instrumental compression has at times resulted in severe ulce- 
I ration and a reawakening of the erysipelatous affection. Multiple 
punctures and incisions, made with a view to giving exit to the fluids 
contained in the mass, have been attended by no greater success. The 
main obstacle in all these surgical procedures is the lymphangitis 
which so frequently complicates the situation. Xone of them promises 
so well as nerve-stretching, which in a few isolated cases has been fol- 
lowed by noteworthy results. Excision of a portion of the sciatic 
nerve has also been followed by satisfactory changes. The use of the 
galvanic current has, when long continued, accomplished resolution of 
j engorged masses of tissue. Elastic compression in the horizontal posi- 
tion for all cases not warranting nerve-stretching may be regarded as 



500 HYPERTROPHIES. 

the wisest course when the extremity is involved. For the local treat- 
ment of the pachydermia proper, green soap, mercurial ointment, and 
bathing with hot or cold lotions may advantageously be employed. For 
patients whose disease is acquired in countries where the deformity is 
prevalent a change of climate is of the highest importance ; and, having 
in view the social surroundings and habits of most victims of the dis- 
ease, it is scarcely necessary to call attention to the need of a proper 
hygiene, diet, and tonic regimen. 

Prognosis. — The future of a patient may be regarded as most favor- 
able when the disease exhibits an early tendency to respond favorably 
to appropriate treatment, and when circumstances permit of a resort to 
the best therapeutic measures which can be adopted, such as change of 
residence, persistent and careful dressing of the affected part, and the 
removal of any exciting cause of the disease, such as neoplasm, an 
indurated cicatrix, etc. In the severer cases a fatal result may occur 
early in the disease ; but usually life is prolonged, burdened by the 
inconvenience of the enormous elephantiasic mass in comparison with 
which the rest of the body often seems to serve as a mere appendage. 



CLASS V. 
ATROPHIES. 



LEUCODERMA. 

(Gr. 2,evk6c 7 white ; dep/ua, skin.) 

(Achromia, Leucasmus, Partial Albinism.) 

Absence of the pigment of the skin and hairs giving rise to con- 
spicuous disfigurement is naturally most frequently encountered in 
those races of mankind Avhose skins are most abundantly provided 
with such pigment. The absence of pigment may be congenital or 
acquired, and be partial or universal. Some confusion has been pro- 
duced by the arbitrary distinction established by authors between the 
names intended to designate these several varieties of achromia or 
leucopathia. In the following pages leucoderma is the name employed 
to designate the pigment-atrophy which is partial and congenital ; al- 
binismus, that which is universal and congenital ; vitiligo, that which 
is acquired. 

In leucoderma, the patients being most often of the colored races, 
one or several whitish or rosy-whitish patches or bands, varying in 
size, outline, or situation, may be seen at birth unprovided with pig- 
ment. These patches may have a symmetrical arrangement, in which 
case they commonly observe the areas of distribution of one or more 
cerebral or spinal nerves ; or they are asymmetrical in distribution. 
They are usually of circular outline, and may be found upon the scalp, 
face, nipple, breast, and genital and other regions. The hairs found 
upon such parts are equally destitute of normal color, being usually 
white. Negroes thus marked are generally termed " piebald," and the 
integument similarly affected in persons of other races has long been 
recognized as the " pied " or " piebald skin." These blemishes when 
symmetrical, like pigmentary nsevi, exhibit a striking analogy with the 
symmetrical arrangement of the spots, bands, and stripes to be recog- 
nized in the furs of many of the lower animals. The outline of the 
patch may be abrupt, or it may gradually shade into that of the adja- 
cent integument. At times islands of pigmented skin are visible within 
the non-pigmented areas. The changes in these patches during later 
life may be insignificant, or they may individually increase in size with 
age, or even multiply. Rarely they regain pigment in later life. In 
no case is there an excess of pigment deposited at the border of the 
patch. 

This condition is practically remediless. 

501 



502 ATROPHIES. 

ALBINISMUS. 

• (Lat. albus, white.) 

(Complete Congenital Leucoderma.) _ 

Symptoms. — The term albinismus is here limited to the congenital 
conditions of achromia induced by universal absence of cutaneous pig- 
ment. 

This deformity is peculiar to individuals known as "albinoes" 
(Kakerlaken; Dondos), isolated instances of this anomaly occurring 
in all races, but more frequently among those having normally a hyper- 
pigmentation of the skin, such as negroes. In the subjects of this 
anomaly the skin has a milky-whitish, transparent, or rosy-tinted hue, 
and is usually of delicate texture; the hairs are silky and yellowish, 
whitish or snowy- white in color ; the iris transparent or pinkish ; and 
the pupil, in consequence of defect of pigment in the choroid, is also 
reddish or pinkish. There are, as a result, nyctalopia and heliophobia, 
with frequent nictitation, pupillary variations, and the semblance of 
myopia. The pinkish hue of the skin in these individuals is due only 
to its translucency and vascularity. The defective condition of the 
pigment is usually unchanged throughout life ; but in no other respect, 
save as to pigment-anomaly, does the skin of the healthy albino indi- 
cate disease. 

Many persons thus deformed, however, are far from vigorous. It 
has been observed that some albinoes are physically inferior to the 
average of persons of the same sex, both in stature, weight, mental 
activities, and powers of resistance to disease. There are, however, 
numerous striking illustrations of the reverse of this, and we have had 
under observation a number of albinoes in one family in which alterna- 
tions of non-pigmented with normally pigmented children exhibited 
no difference whatever in sturdiness and vigor. Many enfeebled 
albinoes are simply illustrations of the wretchedly unwholesome life of 
persons imported for exhibition into foreign countries. 

Etiology. — Inheritance is evidently a strong factor in the produc- 
tion of this and similar pigment-anomalies. Alternations in birth of 
white and of black children in one family have been recorded, yet it is 
unusual to find albinoes in two succeeding generations, an occurrence 
of no great rarity in inherited affections. 

The condition is remediless ; though it is probable that transfusion 
with the blood of a vigorous black-skinned African would largely 
modify the color-characteristics of the pure albino. 

VITILIGO. 

(Lat. vitium, a blemish.) 
(ACQUIRED LEUCODERMA.) 

Symptoms. — The disorder is one observed among the several races, 
often in the negro, and not rarely among those of Aryan descent. It 
commonly occurs without the slightest appreciable disorder, subjective 



VITILIGO. 503 

or objective, save that betrayed to the eye in the color-changes of the 
skin. One or several rounded, or very irregularly shaped, smooth, and 
well-defined, pale or milky-white lines, streaks, or disks appear, often 
bordered at the periphery by an integument which assumes a light- or 
dark-brown or chocolate shade, this hue being by contrast most notice- 
able immediately at the contour of the patch, and imperceptibly fading 
into the normal color of the outlying integument. The hairs or lanugo- 
filaments growing from the affected area may or may not be blanched ; 
most commonly they are, a condition particularly conspicuous when, as 
is not rarely observed, a vitiliginous disk extends from the back or the 
side of the neck well into the scalp, in which case the outline of that 
portion of the scalp involved is clearly defined by the whitened pilary 
growth. Lesser describes a condition termed by him Poliosis Cir- 
cumscripta Acquisita, in which the hairs were thus blanched in a 
single area of an unaffected scalp, an observation which is confirmed in 
many cases. 

The most common seats of the disease are the face, the neck, the 
backs of the hands, the genitals, and the extremities. Upon the backs 
of the hands the disfigurement is usually more conspicuous in summer 
than in winter, a circumstance which probably explains the reported 
instances of recurrence and total disappearance of the disease in suc- 
cessive years. The changes are due to a deepening of the pigment in 
the normal areas on exposure to the sun, thus making a more striking 
contrast with the non-pigmented spots. 

The course of the affection is exceedingly slow ; there may be for 
years no apparent extension of any involved area or the achromia may 
progress by peripheral extension and by the coalescence of relatively 
small affected areas until a large portion of the trunk, the thighs, the 
buttocks, or other part of the body is involved. Hall 1 reports the case 
of a dark mulatto who became " perfectly white," with the exception 
of a patch on the chin. Levy 2 reports three instances of total disap- 
pearance of pigment. It not infrequently happens that the loss of pig- 
ment is so extensive on the face, hands, and other regions that the eye 
of the observer is struck no longer by the unusual whiteness of the 
involved patches, but this whiteness being generalized and apparently 
that proper to the person, the remaining normal areas appear to be 
hyperpigmented. Patients with vitiligo frequently suppose that the 
whitened areas are normal, and the darker ones abnormally pigmented. 
Patients of lymphatic temperament and blonde complexion (often 
women in early adult life) will occasionally apply to a physician for 
relief of dark patches on the skin of the face. Examination discloses 
faint lines, ribbons, or streaks of pigment about one or both cheeks, the 
temples, or the lips. But careful scrutiny recognizes an undue white- 
ness of the skin, with exceedingly faint and irregular outline near or 
next to these pigmented portions of which complaint is made. In 
these cases care is necessary to make a diagnosis between vitiligo and 
chloasma. 

As in several of the other pigmentary disorders of the skin, the 

1 Louisville Med. News, 1880, x., p. 148. 

2 Receuil de Mem. de M£d. de Chir. et de Pharm. mil., 1865. 



504 



ATROPHIES. 



Fig. 61. 



patches of vitiligo may be symmetrical in distribution, with their out- 
lines limited to the areas supplied by certain nerves. The disorder 

shows a tendency to spread, though as a rule a 
limit is reached eventually beyond which the 
atrophy does not progress. In exceptional cases 
the parts which have lost pigment again acquire 
it. 

In vitiligo, aside from the dyschromia, the 
skin is normal. The health of the subjects of 
this disorder is usually unimpaired. A morbid 
mental condition, especially in women of middle 
life, is often produced when the disfigurement 
involves the facial region. 

Etiology. — Vitiligo occurs in both sexes and 
in individuals of all complexions and ages, 
though it is commonly observed among women 
and in early or middle life. It is at times coin- 
cident with scleroderma, lepra, variola, and other 
diseases with similar cutaneous symptoms, though 
it occurs independently of all such. Its etiology 
must be regarded as obscure, although there are 
strong probabilities that it is due to the influence 
of perturbed innervation. It is frequently found 
in connection with functional and organic dis- 
eases of the nervous system and with peripheral 
nerve-lesions. The disorder is of more frequent 
occurrence than dermatological statistics tend to 
show. Many persons who are the subject of 
vitiligo of an inconspicuous part of the body do 
not consult a physician with regard to the nature 
of the disease, as it occasions no physical distress. 
Pathology. — The pigment normally present 
in the deep rete-cells is absent in vitiligo-spots, 
but greatly increased and deepened at the bor- 
ders of the areas. In the corium are cells which 
contain pigment-granules. These are especially 
numerous at the margins of patches, where blood- 
vessels, follicles, and glands are surrounded by 
many oval, stellate, and branched pigment-cells. The probable nature 
and origin of these cells are considered with chloasma. Leloir and 
Chabins have demonstrated atrophy of the subdermal nerves in patches 
devoid of pigment. Other changes in the skin have not been noted. 

Diagnosis. — The diagnosis is based on the presence of achromia, 
with usually a hyperpigmented border, and the absence of all other 
symptoms or changes, such as would be found in tinea versicolor, mor- 
phoea, lepra, or syphilis. From the chloasmata, which are always 
accompanied by hyperpigmentation, vitiligo is readily differentiated. 
Treatment. — Much chagrin will be saved both physician and patient 
by practically regarding vitiligo as not amenable to treatment. Patients 
occasionally recover while under treatment, which, however, has gen- 




■1 




Vitiligo in a negro boy. 
(Piffard's case.) 



CANITIES. 505 

erally contributed but little to the result. Arsenic and iron internally, 
recommended highly by some authors, have repeatedly failed to accom- 
plish any appreciable results as regards dyschromia. By efforts directed 
to the removal of the hyperpigmentation in the border of the achromic 
patches the disfigurement may be somewhat lessened. The method of 
arriving at this end is described in connection with the treatment of 
chloasma. It is possible that further experimentation with hypoder- 
matic injections of pilocarpine, that have in a limited number of cases 
been followed by disappearance of the disease, may warrant a less 
unfavorable view of the results of treatment. Savill 1 reported a 
return of normal color in vitiliginous patches to which he had applied 
pure carbolic acid. 

Prognosis. — The health of the subject of the malady is not impaired. 
The disease is practically incurable, progressing usually until it has 
obtained a maximum of development ; and then, as a rule, remaining 
unchanged throughout life. 

CANITIES. 

(Lat. canus, white.) 

(Trichoxosis Cana, Poliothrix, Hoarixess, Poliosis.) 

Symptoms. — In this anomaly the hairs appear in all shade of white- 
ness, from dirty gray or yellowish white, to a steel gray or silvery 
1 white. This may be either a general or a partial, congenital or acquired, 
physiological or pathological, prematurely, rapidly, or gradually 
acquired condition. General congenital whiteness of the hairs is seen 
in albinismus, where pigment has never colored the filaments. Partial 
congenital whiteness is occasionally seen in patches, limited in size 
and varying in color from pure white to a deeper hue, that from birth 
do not receive pigment in due proportion, thus contrasting with the 
pigmented filaments by which they are surrounded. 

Physiological decoloration of the hairs in variable shades is the 
well-known result of advancing years. When premature, it may 
result from pathological causes or be due to individual or inherited 
peculiarities. It may occur gradually or suddenly ; in the former 
case the hairs usually pass through varying shades of gray to white, 
and this at any period after (occasionally before) puberty, though 
commonly after middle life is reached. Recurrence to the darker 
shades is rarely noted. Leonard, of Detroit, 2 cites a number of curious 
instances in which changes of this sort have occurred. Generally, 
however, canities of advanced years is progressive and permanent, 
, occurring earliest on the temples and the beard of man, then involving 
the vertex of the head. Finally, the hairs of the entire body-surface 
undergo similar pigmentary loss. Trichoxosis Versicolor (TTilson), 
" Rixged Hair/' occurs in sound individuals of both sexes, the pilary 
filaments having the appearance of a foreign body interspersed among 
the hairs. Close examination reveals the presence of alternating rings 

1 Brit. Jour, of Derm., March, 1898. 

2 The Hair, etc. Detroit, 1880. 



/ 



506 ATROPHIES. 

of different shades of color twenty to thirty to the inch of the hair- 
shaft. 

It should be remembered that the coloring of the hairs of the head 
is, to a greater extent than is commonly appreciated, subject to varia- 
tion from the operation of external causes. Thus, washing the hair 
with alkaline solutions has a bleaching effect, while profuse sweating, 
inunction with fats, subjection to smoke, and the temperature-changes 
of the summer have the contrary influence, the last named being pos- 
sibly associated with increased sweating in the hot season. 

Cases of sudden blanching of the hairs, occurring, for example, in 
a single night, are sufficiently numerous and well authenticated to be 
admitted as among the rare possibilities of a clinical experience. Ner- 
vous disorders, both centric and peripheral, such as long-continued 
mental depression, melancholia, paralysis, neuralgia, and traumatism 
of nerves or of nervous centres, may be followed by more or less rapid, 
general or partial, and permanent canities. The same result may fol- 
low wasting disorders, such as typhoid fever, tuberculosis, syphilis, 
and malarial (Chagres) fever, in which cases, as distinguished from 
the others, pigmented hairs may eventually replace those which were 
white. The first hairs springing from a patch of alopecia areata in 
which repair is in progress are often white or whitish, and are replaced 
later by those of normal color. Cases are reported in which the pres- 
sure of a truss or of a corset has produced patches of vitiligo and 
canities. 

Landois has shown that many instances of suddenly occurring cani- 
ties depend solely upon the rapid appearance of air-bubbles in excess 
of the average number in the hair-shaft. 

Etiology. — Whitening of the hair may be senile in origin, in which 
case it is customary to declare it to be physiological ; or be due to 
heredity ; to deficient nutrition or innervation of the hair-follicles ; to 
functional or organic nervous affections (fright, facial atrophy, etc.) ; 
or to local chemical action upon the hairs. Premature canities in 
young adults is often associated with the occupations of life, being 
much commoner in men who from necessity have the head habitually 
covered and who yet lead sedentary lives. 

Pathology. — The color of the hair is dependent upon the pigment 
situated in the matrix and between the horny cells, and upon the 
natural yellowish color of the dried horny cells. In source and char- 
acter the hair-pigment is undoubtedly identical with that of the skin 
in general. This has been considered with chloasma. Decoloration 
of the hairs may be due to failure of supply or to removal of pigment ; 
to unevenness of the hair-surface (by which light is refracted) ; or 
to air-bubbles between and within the fibre-cells. In senile and pre- 
senile decolorations there is commonly actual diminution of pigment. 
Rapidly occurring canities is ascribed to the sudden appearance of air- 
bubbles in quantity in the shafts of the hair. Alterations of color in 
the hairs are attributed to successive periods of activity and rest in the 
pigment-producing cells. 

Treatment. — The chief means of remedying premature canities is 
by the action of dyes, which are, in the main, compounded with solu- 



'ALOPECIA. 507 

tions of silver nitrate, lead acetate, and ferrous sulphate. The main 
objections to their use are the disagreeable coloring of the scalp which 
results from incautious use of the dye, and the consequent liability to 
irritation of the surface. When applied to the hair alone these sub- 
stances are not known to have a deleterious effect upon the health. 
Kaposi gives the following formulae for hair-dyes : 
To obtain a black color — 



Or 



R Argent, nitrat., gr. xv ; 1 

Amnion, carb., gr. xxij ; 1 

Unguent, adipis, ^j ; 30 



5 



M. 



R Argent, nitrat., 3j ; 4 

Plumb, acetat., gr. xv; 1 

Aq. Cologn., gtt. xv; 1 

Aq. ros., adf^iij; ad 90 

To obtain a brown shade — 

R Acid, pyrogal., 
Aq. Cologn., 
Aq. ros., 



M. 



gr. xv ; 


1 


3ss; 


2 


3jss ; 


45 



M. 



Anderson first applies a lotion of mercuric chloride, 2 grains to the 
ounce (0.133 to 30.), and follows this with a solution of sodium hypo- 
sulphite, 1 drachm to the ounce (4. to 30.), for the production of a 
jet-black shade. In the way of constitutional treatment, he suggests 
in cases of accidental presenile blanching strict attention to the gen- 
eral health and arsenic internally. 

ALOPECIA. 

(Gr. al&Tcri^ a fox.) 

(Calvities, Defluvium Capillorum, Deficiency of Hair, 
Baldness. Ger., Kahlheit.) 

The simple term alopecia is no longer descriptive of a disease, but 
only of a symptom, loss of hair, which occurs in a large number of 
morbid and even physiological states. For convenience of description 
the alopecias may be enumerated as congenital alopecia, senile alopecia, 
premature or presenile alopecia, and alopecia areata. 

• Congenital Alopecia. — In rare cases there is a partial or a complete 
absence of hairs at birth, in consequence of arrested development of 
the pilary system. Generally, however, these appendages of the skin 
are merely of tardy appearance, their eruption being extraordinarily 
delayed, as in retarded dentition. In some instances the hair falls 
after birth and never returns. When the alopecia persists to adult 
years, as is rarely the case, there is usually defective development also 
of teeth and nails. 

In localized congenital alopecia hairs rarely develop after maturity, 
and here, also, abnormalities of teeth may be coincident features. In 



508 ATROPHIES. 

a case of congenital alopecia examined by Scliede l the sebaceous glands 
were found opening on the free surface of the skin. In the deeper 
part of the cutis straight or convoluted hair-rudiments were visible in 
the tubules, without perceptible internal cavity, which corresponded 
with the external root-sheath. 

Senile Alopecia. — The baldness of old age, whether occurring upon 
the vertex so as to produce a tonsure like that of the priest, or whether 
limited to the frontal region, or so extensive as to involve nearly the 
entire calvarium leaving a fringe of hairs at the occiput and temples 
merely, is always remarkable for its symmetry. There is, hence, a 
certain degree of dignity added to the appearance of the head that an 
asymmetrical loss of hair does not produce. It may occur at varying 
ages of advanced life, and is frequently traceable to an early seborrhoea 
sicca or alopecia furfuracea. It is much commoner in men than in 
women, largely because of the difference in the manner of covering 
the head in the two sexes, women usually wearing an exceedingly light 
dress for the head, while men encase the latter with tight-fitting caps 
or hats which interfere with proper aeration of the scalp. Individ- 
uals of the male sex, also, in consequence of their usually wearing the 
hair short, bestow far less time upon the care and dressing of it. In 
uncivilized races these differences are less marked, men pay great 
attention to the ornamentation of the scalp, and senile baldness is of 
less frequent occurrence. 

The bald surface, as a rule, is smooth and shining ; it is occasionally 
the seat of a seborrhoea oleosa. The hair-follicles, with their accessory 
sebaceous glands and occasionally the skin itself, are often in a state of 
atrophy, though there may be dilatation of the sebaceous glands. There 
is commonly blanching of the hairs, which are gradually shed, as also 
of those which remain, though the canities is not constant. This con- 
dition is much less frequent upon the surface covered by the beard and 
pubic and axillary hairs, where, according to Michelson, the hairs in 
advanced years are often denser than at other periods of life. 

Premature or Presenile Alopecia (premature calvities) is that form of 
acquired baldness which occurs in individuals who have not attained 
advanced years. Idiopathic and symptomatic forms are recognized by 
writers, though it is probable that a definite cause exists for cases 
occurring in individuals under forty-five years of age. 

The Idiopathic variety does not originate in the diseases of the 
scalp or of the general economy that are recognized as effective in the 
production of other forms of baldness. In many cases, however, 
classed as idiopathic a careful search will reveal the presence of a 
seborrhoea. It is, as with senile alopecia, more common in men than 
in women, and is in the former sex decidedly prevalent among those 
leading sedentary lives. The loss of hair may be produced either 
rapidly, or, more commonly, slowly, and at any period after the puberal 
epoch. It is always symmetrical and usually remediless, partial cal- 
vities being the permanent result of the process. The pilary growth 
may gradually and evenly recede from the forehead, or, what is more 
frequent, recede from the temples on either side of the median line, 

1 Arch. f. klin. Chir., Bd. xiv. 



ALOPECIA. 509 

leaving a more vigorous crop extending centrally toward the root of 
the nose, or produce the effect of the tonsure described above. In many 
families there is a predisposition to this premature loss of hair, usually 
in the form of the receding temple, that may be recognized in the males 
of succeeding generations. ' 

Symptomatic Presenile Alopecia may result from a number of 
systemic and local conditions. Loss of hair (Defluvium Capillorum) 
is common after typhoid and other fevers, and after other conditions 
interfering with the nutrition of the scalp. Frequently the hairs do 
not fall for some weeks after the patient has recovered from the consti- 
tutional disturbance, but remain in their follicles until pushed out by 
the new hairs, or until gradually pulled out by the use of brush and 
comb. In these cases there is usually a general and symmetrical thin- 
ning of the hair. The loss is not permanent, as new hair gradually 
replaces that which has fallen. The alopecia of the early periods of 
syphilis is of this order, but occurs in characteristic patches. A slower 
loss of hair is seen in many cachectic conditions such as tuberculosis, 
diabetes, leprosy (in which the alopecia is limited often to the eyebrows 
and eyelids), and myxoedema. 

Of all the local causes of alopecia, seborrhoea in some form is the 
most frequent. 

Alopecia Furfuracea, Pityriasis Capitis, or Alopecia 
Pityrodes Capillitii. — Losses of hair varying from moderate 
thinning of the growth to considerable symmetrical baldness, usually 
of the vertex, accompany the pityriasic forms of seborrhoea or eczema 
seborrhoeicum of the scalp. The affection is exceedingly common, 
especially in men. 

The disorder, essentially chronic in course, is usually first manifested 
in early adult life, though persons of both sexes, from tw r elve to fifteen 

I years of age, may at these ages display typical forms of the disease. 
After the condition known as Dandruff has existed for some months 
or years the subject of the affection discovers a relatively large loss of 
hair from the scalp, producing thinness of the growth upon the vertex, 
near the brow, or over the temples. The hairs, when examined in situ 
upon the scalp, are shortened, dry, harsh, lustreless, and rarely well 

| anointed with sebum. They are rebellious to comb and brush, and 
project irregularly from the brushed surface. Those shed from the 

: scalp, especially of men, are found to be nearer in type to the lanugo- 
or downy hairs than those which fall physiologically from a vigorous 

j growth of hair in a healthy subject; that is, they are short, thin, 

! pointed, and often with an indistinct medulla. 

At the same time the scalp is in process of incessant desquamation, 

• the scales usually being of pityriasic type, and exceedingly abundant 

k so long as the alopecia is not complete, after which the epidermal catarrh 
soon disappears. The mealy, bran-like scales are shed in a fine shower 
upon the clothing of the patient, and, the disease being more common 

( in men than in women, its traces are often distinct upon the collar of 
the coat after the fingers have been passed through the hair. The 

: same flour-like, whitish and grayish scales are distinct and plentiful 
among the hairs to which they cling, and they can also be recognized 



510 ATROPHIES. 

over the scalp-surface when the latter is inspected with care. Itching 
is often marked ; the scalp may be scratched and torn by the nails, 
and is, in some cases, reddened and thickened. The condition is prone, 
sooner or later, to develop the severer phases of seborrhcea and eczema 
seborrhoe'icum. 

Other local causes of alopecia are found in various inflammatory 
disorders of the scalp, such as psoriasis, eczema, etc. ; in morphoea, and 
lupus erythematosus ; in syphilitic, tubercular, and other destructive 
lesions ; in some forms of folliculitis (considered in the succeeding pages) 
in which the follicle and surrounding tissue are destroyed by suppura- 
tion ; in ringworm and favus ; and in traumatism, which may occur as 
a bruise or be the result of scratching or rubbing. 

The forms of alopecia described above as encountered upon the scalp 
may involve also other hairy portions of the body, as of the axilla) and 
the pubes ; and these also in variable degrees. 

Alopecia Akeata is considered in a separate section. 

Etiology and Pathology. — The causes of congenital alopecia are 
not known. Senile alopecia is attributed by many to the general atrophic 
changes which take place in the aged. This atrophy evidently will not 
explain the cases, often classed as senile alopecia, occurring in men 
under sixty or seventy who are in all other respects vigorous and well. 
Most cases of so-called idiopathic presenile alopecia are due to an un- 
recognized seborrhoea. The symptomatic alopecias should be studied 
with the conditions upon which they depend. 

Treatment. — In symptomatic alopecias the underlying conditions, 
local or systemic, must be treated by measures appropriate to each case. 
The general health should always be considered, and any condition 
interfering with the nutrition of the scalp and hair should be removed 
as speedily as possible. 

Local treatment is of importance in nearly all cases, and in general 
is directed toward stimulating the nutrition of the hair-follicle by pro- 
ducing in its periphery a species of transitory and artificial hyperemia. 
This result is usually accomplished by daily brisk, but light, friction 
of the scalp with a brush, or by massage with the fingers, aided by the 
local employment of one or more of the alcoholic, oily, alkaline, and 
other stimulating applications described below. The hat should be light 
and well ventilated, and worn as little as possible. 

Local treatment may often be preceded by shampooing with either 
the Sarg fluid soap, or combinations of glycerin, alcohol, and sapo viridis 
to meet the requirements of individual cases. The scalp after all such 
shampooings should be anointed with lanolin, plain or salicylated ; 
vaselin ; equal parts of lanolin, glycerin, and rose-water ; the" oil of 
benne; or scented castor-oil. In obstinate cases the nail-brush may 
be used vigorously over insensitive scalps at the time of shampooing. 
The ointment-bases named above may often be medicated advantage- 
ously with sulphur, resorcin, chrysarobin, tar, cantharides, or mercury. 
Instead of ointments, lotions containing cantharides, carbolic acid, cap- 
sicum, resorcin, mercuric chloride, ammonia, or nux vomica may be used. 
Formulae for lotions and salves to be used in this way are appended : 



R 



R 



R 



R 



ALOPECIA. 






Hydrarg. chlorid. corros., 




gr. v; 


33 


Spts. vin. rectif., 




^ij ; 


60 




Acid. acet. dil., 




3ij ; 


8 




Glycerin., 




^ss; 


15 




Aq. ros., 




Ivj; 


180 


M. 


Hydrarg. bichlorid., 




gr- "J 1 




20 


Tinct. cantharid., 




^ss ; 


15 




01. amygdal. dulc, 




33; 


4 




Spts. rosmarin., 




l]\ 


30 




Spts. vin. rect., 




Sy; 


60 




Aq. destill., 


q- 


s. ad £vj ; 


q. s. ad 180 


M. 


Sulphur, prsecipit., 




33; 


4 




Lanolin., ] 










Glycerin., V 




aa 3ijss ; 


aa 10 




Aq. rosse, J 








M. 


Hydrarg. chlorid. mit., 




Biv; 


5|33 


Hydrarg. ammon. chlor., 




Bij ; 


2J66 


Vaselin., 




ad gj ; 


ad 30 


M. 








[Br on son.] 



511 



The addition of acetic acid to a scalp-lotion seems to favor penetra- 
tion of other remedies. Pilocarpine hypodermatically has given good 
results. Further suggestions regarding the details of treatment of alo- 
pecia, and the special remedies recommended for alopecia furfuracea, 
are given under Seborrhoea sicca. 

Prognosis. — Congenital, senile, and many of the so-called presenile 
idiopathic alopecias are practically remediless, though in the two last 
forms further loss of hair can be prevented or greatly retarded by 
proper treatment. The symptomatic alopecias in which there is 
destruction of the hair-follicle, as in lupus erythematosus, syphilitic 
ulcers, favus, and some forms of folliculitis, are permanent ; those due 
to systemic disorders and to local inflammations are usually temporary. 
In alopecia furfuracea persistent treatment will prevent further loss of 
hair, and in recent cases may produce a new growth. 



ALOPECIA AREATA. 

(Lat. area, a vacant space [arere, to wither, Fox].) 

(Poeeigo Dec al vans, Tinea Decalvans, Aeea Celsi, Aeea 
Johnstone, Alopecia Ciecumsceipta. Fr. y Pelade.) 

The hair-loss is limited usually to the scalp, but may occur upon the 
beard, the genitalia, axillae, brows, eyelids, and the general surface of 
the body. Cases occur, especially in early childhood, in w T hich the 
closest scrutiny with a glass fails to detect a single filament of hair 
upon any portion of the skin. 

The disease commonly manifests itself by the sudden and complete 
loss of hair over a circinate, circumscribed patch, usually upon one side 
of the scalp, so rapidly effected that a first discovery of the fact may 
be made at the toilet of the morning:. In other cases the loss of hair 
is gradual, the patch attaining large dimensions in the course of two or 



512 ATROPHIES. 



three weeks. Less frequently an area of baldness will continue to 
extend peripherally for many weeks. Instead of one area, there com- 
monly are several, which may develop simultaneously or at varying 
intervals. 

The patches may be round, oval, circinate, or irregularly shaped, 
and may vary in size from that of a small coin upward. They may 
be so numerous as to disfigure the entire scalp, and though they touch 
at the borders they can scarcely be said to coalesce, as the individual 
areas are usually recognizable. Their surface is smooth, soft, whitish, 
and usually destitute of hairs. The affected scalp may be thinner and 
more lax than normal, and often is slightly depressed below the level 
of the surrounding skin, but in rare instances it is tumid and slightly 
reddened. As a rule, there are no subjective sensations, though the 
affected areas may be the seat of slight pruritus, or of anaesthesia, and 
are nearly always less sensitive to irritating applications than the sur- 
rounding normal parts. 

The hairs at the periphery of patches that have attained their 
full development are normal in every way, and are firmly implanted in 
their follicles, but at the borders of areas which are still spreading the 
hairs are loose and fragile, often broken off near the surface, thus 
leaving short stumps which exhibit at the bulb a spade-like extremity 
or an attenuated point, the non-atrophied shaft thus contrasting with 
the wasted portion implanted below the cutaneous level. Crocker 
likens their shape to that of the exclamation-point. Newly formed 
areas may be covered in greater or less degree with these character- 
istic hairs, which, however, soon fall out. 

The course of the disease is variable ; it may persist for months or 
years without apparent change ; or new patches may form while those 
of an older date gradually regain wholly or in part the pilary growth 
which, however, may be lost repeatedly in the same area. Shifting 
areas of baldness may in this manner invade the entire surface of the 
scalp, which yet at any one moment of time exhibits a loss of but part 
of its hirsute covering. 

When the filaments begin to reappear there is commonly a fine, 
downy growth over the affected area, later replaced by a crop of 
thicker and stronger whitish filaments, which are always succeeded, in 
cases terminating favorably, by a growth of hairs as well colored, as 
vigorous, and as persistent as any which were at first lost. An odd 
appearance is often presented by patients who are improving, when the 
strong and white new hairs contrast vividly with the dark shade of 
those on the unaffected scalp. 

This disorder, which is more common than is generally believed by 
physicians, may, in some cases, at its outset be preceded or be accom- 
panied by symptoms of ill health, such as headache, malaise, inappe- 
tence, loss of flesh, or malnutrition. In other cases, cephalalgia, 
paresthesia, pruritus, and formication of the skin of the scalp and 
other regions indicate disturbance of the nervous centres. Often, how- 
ever, patients of this class are in sound health. 

Among the unusual features of the disease may be mentioned the 
occurrence of alopecia in bands or streaks ; at the site of an injury or 



: 



ALOPECIA. 513 

along the course of a nerve ; or over the entire body, removing even 
the finest lanugo-hairs. Universal alopecia may occur suddenly, or as 
the result of a gradual thinning of the hair, or may follow the exist- 
ence of the disease in characteristic areas. This variety of alopecia, 
which is fortunately rare, usually occurs after the middle period of 
life, but it may develop in the very young. 

In some instances alopecia areata is associated with other cutaneous 
diseases. It is not rare to discover alopecia areata in patches which 
are also the seat of the vegetable parasites. A male patient, long 
psoriatic, under our observation exhibited a typical seborrhcea capitis, 
and later developed a no less typical alopecia areata. 

The course of the disease in young subjects is usually toward a favor- 
able result. There is hope, as a rule, when even the downiest and 
thinnest growth, requiring a good light and a glass for its recognition, 
can be appreciated. E\ r en when so feebly attached that these filaments 
are removed with ease by the fingers or a brush, and when they spon- 
taneously fall they may be replaced by crop succeeding crop of 
stronger filaments, which eventually persist. In serious cases, usually 
after the forty-fifth year of life, and in those of long standing, there 
may be absolute atrophy of the hair-follicles and a resulting remediless 
baldness. 

There is some reason for believing that the disease has a stadium 
of evolution and involution, though its exact limits are not known. 
Few individuals fully recover the hair in less than one year. The 
majority attain the desired end within a period of two years. These 
limitations, however, apply to the asymmetrical forms of the disease 
in the relatively young. The symmetrical alopecia areata of the 
middle-aged is a far more formidable affection, though in many of 
these cases, when the loss is recent, proper treatment will restore the 
hair. 

Few diseases are the source of greater mental distress than those of 
the class under consideration. The prominent deformity debars the 
subject of the malady from social relations of many kinds, and this 
intensifies the morbid feeling which every reflected view of the head 
awakens. This fact is particularly true of women. The successful 
management of these cases calls often for the supporting assurances 
of the practitioner. 

Alopecia Circumscripta seu Orbicularis is a rare form de- 
scribed by ISTeumann in which the areas are much depressed, are the 
size of a pea or smaller, and are decidedly anaesthetic. The prognosis 
is unfavorable. 

Etiology. — The question of the parasitic or neuropathic origin of 
I alopecia areata is still undecided, though it has been the subject of 
extended discussion and observation. It is highly probable that many 
of the limited, asymmetrical forms of the disease, in which the patches 
increase by peripheral extension, are due to parasites not yet recog- 
nized. The efficacy of some such agency, is suggested in epidemics of 
the disease which have been reported both in France and in America, 
where entire companies of a regiment or numbers of inmates of public 

33 



514 ATROPHIES. 

institutions, have suffered from the disease in an apparently contagious 
form. Eichhorst, Thin, Von Sehlen, 1 Robinson/ Bowen, and others 
discovered in affected patches and about the bulbs of hairs in alopecia 
areata micro-organisms which were cultivated in generations, but 
which were not shown to be effective in the production of the disease 
de novo. In a series of three hundred cases Sabouraud found in the 
early stages of the disease a micro-bacillus. He obtained pure cultures, 
with which he produced typical areas in calves, rabbits, and guinea- 
pigs. He finds the same bacillus in comedo, acne, and seborrhoea, and 
believes that alopecia areata is an acute form of seborrhoea oleosa. The 
frequent coincidence of alopecia areata and tinea tonsurans suggests an 
etiological relationship. 

The weight of evidence in favor of a neuropathic origin of some cases 
of the disorder is great, and is very generally accepted by authorities. 
The sudden occurrence of extensive symmetrical or of universal alo- 
pecia can hardly be explained in any other way. Mental emotion 
(anxiety, fright), anaemia, malnutrition, traumatism both general and 
local (falls upon the head, blows inflicting lacerated wounds of the 
scalp), and bodily injuries of the general surface have all been cited as 
effective. The nervous symptoms which often precede or accompany 
the appearance of the bald patches are strikingly suggestive, and the 
occurrence of the disease after shock of the nervous centres is signifi- 
cant. Cases of this type are classed by Michelson and others as Alo- 
pecia Neurotica. Max Joseph produced baldness in patches upon 
the ears of cats and rabbits by section of the second cervical nerve 
near the intervertebral ganglion. 

Alopecia areata occurs with equal proportion in the two sexes, and 
among these irrespective of social condition. Of the partial and asym- 
metrical forms, the larger number of cases occurs in young subjects, 
from childhood to early adult life. The severe and generalized forms 
are more often encountered in middle-aged persons. In the latter class 
especially the disease is occasionally observed to follow the obscure dis- 
orders of the nervous centres due to sudden or prolonged undue excita- 
tion. In young subjects a peculiar repugnance to the ingestion of fat 
and meat may often be discovered. 

Pathology. — The anatomical lesions in alopecia areata have not 
been recognized definitely. The hairs fallen from the surface, when 
examined, with the microscope, are seen to be atrophied in bulb and 
shaft, as in other forms of alopecia. Fracture of the shaft is in some 
cases also noted, evidently an accident of the process. 

As a^ result of careful examination of many pathological sections, 
Gioyannini 3 and Robinson 4 believe the disease is primarily an inflam- 
mation of circumscribed areas of the corium, and especially of the sub- 
papillary layer. In a small patch of one week's duration Robinson 
found marked perivascular cell-infiltration in a limited region of the 
corium, the papillae being but mildly affected, while the epithelium, 

1 Annal. de Derm, et de Syph., June, 1886. 
2 Monatshft. f. prakt. Derm., 1889, vii., p. 409. 
3 Annal. de Derm, et de Syph., 1891, p. 921. 
4 Morrow's System, vol. iii., p 865. 



ALOPECIA. 515 

rete, subcutaneous tissue, and glands were normal. Some of the hair- 
follicles were normal, while in others no papillae could be found, and 
the hairs were wanting or imperfect. In cases of longer standing 
evidences of inflammation were more marked and extensive, and there 
were vessels with thickened walls and narrowed lumina. In some 
cases there was more or less atrophy of all elements of the corium, 
with destruction of the hair-follicles and sebaceous glands. Giovan- 
nini, who describes an invasion by leucocytes of the hair-follicle, con- 
siders the process a deep-seated folliculitis. 

Sabouraud finds constantly in the early stages large numbers of 
his micro-bacillus surrounded by keratinized epithelium, forming a 
cocoon-shaped mass which occupied the much dilated follicle-neck. 
In the later stages of the disease he finds no bacilli, but describes 
inflammatory changes, atrophy of the follicle, and achromia of the 
basal layer, all of which he ascribes to the influence of local toxins. 

Diagnosis. — Alopecia areata is to be distinguished from vitiligo of 
the hairy portions of the surface by the preservation of the pilary 
growth in the disease last named, the filaments, moreover, having 
usually a blanched and whitened look, due to the absence of pigment. 

From ringworm and favus of the scalp the disease in question is 
differentiated by the suddenness of its onset ; the absence of stumps 
of hairs, scales, crusts, and evidences of irritation in the involved area ; 
the whiteness, smoothness, and complete baldness of the latter ; and, 
above all, by the failure to detect with the microscope the evidence of 
the presence of a vegetable parasite. Ringworm and alopecia areata 
may coexist. In cases of so-called " bald-ringworm " the diagnosis 
must rest upon the microscopical findings. 

The asymmetrical patches of seborrhoea of the scalp are recognized 
by the presence of the fatty plates pasting the hairs to the scalp-sur- 
face, as well as by the slow and very gradual onset of the disorder. 

Other forms of baldness than those named above are all of gradual 
and, in their early stages, of symmetrical development. Those result- 
ing from traumatic injuries of the scalp with cicatricial results, are 
easily determined as having such an origin. 

Treatment. — One necessarily views with distrust all treatment 
for that disease which in the course of months or years usually termi- 
nates in spontaneous recovery, and in the meantime may bid defiance 
to each and every therapeutic measure. Nevertheless, persistent and 
hopeful management of even apparently desperate cases is occasion- 
ally rewarded by such brilliant consequences that, however slight may 
be the foundation for a belief in the value of the therapy employed, 
it deserves recognition and trial. 

The hygienic management of every case is a matter of importance. 
The general condition of the nervous system should be considered and 
may call for changes in the habits of working, eating, resting, and 
exercising. Tobacco in every form should be denied to subjects of the 
disease. Iron, quinine, nux vomica, cod-liver oil, phosphorus and the 
hypophosphites, arsenic, and strychnine are often indicated, and used 
with great benefit. 

There are few patients who are not benefited by daily salt-and- water 



516 ATROPHIES. 

bathing of the entire body-surface, followed by brisk friction, espe- 
cially over the spinal region. In the case of children this treatment 
must be conducted by a skilled hand. When practicable the cold 
douche is to be preferred. 

In all cases in which the scalp is involved in either sex, and in 
which the special hypochondriasis of the disease is developed, a wig 
should be worn for the sake of its moral effect upon the sufferer. Its 
use, however, should be limited to social occasions, visits, etc., as the 
persistent wearing of a peruke indoors seems to lengthen the course of 
the disease. 

The indication for local treatment is to destroy any parasites that 
may be present and to increase the physiological afflux of blood to the 
hair-follicles. With this end in view the affected parts are to be bathed 
daily in water as hot as can be tolerated, then dried, and rubbed with 
a stimulating lotion. After the lotion dries it is well to apply an oil 
or simple ointment. The articles usually employed are alcohol, ether, 
resorcin, formalin, turpentine, ammonia, camphor, cantharides, carbolic 
acid, oil of mace, croton-oil, tincture of nux vomica, tincture of cap- 
sicum, tinctiu'e of aconite, castor-oil, tar, iodine, sulphur, and the mer- 
curials. All frequently fail. Several of these substances in combina- 
tion seem at times to be of service. 

The following is a formula, the ingredients of which may be varied 
to suit the indications in different cases. 

R 01. ricini, 

Acid, carbolic, 

Cantharid. tinct., 

01. rosmarin., 

Spts. vin. rectif., adf^iv; ad 120l M. 

Sig. For external use over the scalp with friction. 

The preparations containing sulphur, resorcin, pyrogallol, chry- 
sophanic acid (which has the disadvantage of staining the hair), mer- 
curic chloride, etc., given on a preceding page in connection with the 
treatment of seborrhoea capitis, are often valuable. 

Formalin in solutions of 0.5 to 2 per cent, is sometimes efficient. 
It should be used with care, however, as it has occasioned severe der- 
matitis, and in several instances has given light hair a green color. 

Jackson recommends liquor amnionic fortior, applied once or twice 
daily to the bald areas. Speedy return of hair in a patch of alopecia 
areata has followed the application of pure creosote and also of tri- 
kresol to the denuded surface, resulting in moderate vesication. The 
spirit of turpentine and pure carbolic and acetic acids have similarly 
been employed ; but caustic applications are to be used with caution. 

By many experts, having in mind the probability of a parasitic 
origin, epilation is practised to the extent of removing all the loosened 
hairs and a narrow zone of sound hairs about each patch. By others, 
shaving of the patches is substituted for epilation. The remedies 
selected for application are of the order of parasiticides ; for example, 
mercurials, sulphur and its compounds, chrysarobin, pyrogallol, and 
iodine. 



f^ss ; 

3j; 

gss; 


15 
4 

15 


gtt. xv ; 
ad f^iv; 


1 

ad 120 



ALOPECIA. 517 

Repeated blisterings of the scalp with cantharidal collodion, croton- 
oil, spirit of green soap, and petroleum have also been employed with 
success. The ointment of chrysarobin has the disadvantage of staining 
not only the remaining hairs, but often also the face in consequence of 
the frequency of a transmission to that locality through the medium of 
the hands. When patients, however, consent to the use of chrysarobin 
it is worthy of trial, as its application has been followed by a vigorous 
growth of new pilary filaments. Andre employed ten hypodermatic 
injections of pilocarpine muriate in ^ grain (0.008) doses, which 
resulted, in the case of a middle-aged woman affected with total sym- 
metrical baldness, in an abundant growth of hair. Mercuric chloride 
has similarly been employed. 

Faradization of the scalp with a stiff wire-brush, pushed to the 
point of producing moderate hyperemia, has been followed by excel- 
lent results. 

Wilson recommends : 

R 01. amygd. dale, f %] ; 30 

Capsici tinct., f 3>ij ; 8 

Liq. ammon. fort., f % j ; 30 

Spts. rosmarin., f^v; 150 

01. limon., f 3j ; 4 



M. 



Another stimulating application is : 



R 01. terebinth., | aaf^ss; aa 15 

Ol. ricini, j ° ' 

Origani tinct., f Z j ; 4 

01. camphorat., f §j ; 30 

Liniment, volatil., adf^iij; ad 90 

Sig. For external use with a brush until the scalp is irritated. 



M. 



Shaving should regularly be practised when in men the region of 
the beard is involved, as the deformity is thus rendered less conspicu- 
ous ; and the bald surface should be stimulated frequently with one or 
several of the topical applications named above. Alcoholic solutions of 
resorcin (3 to 20 per cent.) or of mercuric chloride, ^ to 1 grain (0.033- 
0.066) to the ounce (30.), are to be well rubbed over the patch or patches 
once or twice daily. 

Prognosis. — From what precedes, it will be inferred that, as re- 
] gards the relief of the baldness, the asymmetrical development of alo- 
pecia areata in youth is much more favorable than the symmetrical 
j general disease of middle life, the latter being often remediless. In 
all cases the practitioner should actively persevere to the end. In no 
1 case should any encouragement be given as to complete relief within 
' the year, though such exceptionally short careers of the disease 
. are at times observed. The prognosis of the same affection of the 
I beard is quite favorable, the disease, in young men, usually conclud- 
ing its stadium in the course of about one year, with a favorable ter- 
mination. 



518 ATROPHIES. 

ALOPECIA FOLLICULARIS. 

(Folliculitis Decalvans. Fr., Folliculites et Perifollicu- 
lites Destructives du Follicule Pileux, Folliculites 
et Perifolliculites Decalvantes, Alopecies Cicatri- 
cielles Innominees, Acne Decalvante, etc.) 

A series of closely related yet differing forms of folliculitis and 
perifolliculitis may involve the hair-follicle and its adjacent parts, de- 
stroying not merely the hair-bulb, but also the hair-papilla. As a 
result these conditions are followed by permanent alopecia and by the 
production of scars. The inflammatory nature of the process is usu- 
ally though not always apparent. There is commonly a marked 
tendency to grouping of lesions, but they may be scattered and iso- 
lated. These disorders, studied with special care by French observers, 
are yet but imperfectly understood, and none is perfectly distinguished 
from the other dermatoses resulting in hair-loss. 

The following types of disorders, many of them of great rarity, 
some observed by but few experts, are recognized by Brocq : 

(a) Cicatricial alopecias in small irregularly disseminated plaques. 
These can be recognized when any scalp that has been the seat of a 
severe alopecia pityrodes is minutely studied. They are probably 
accidental results of that morbid condition, and are due to infection of 
the follicles with cocci. 

(6) Cicatricial alopecias of the scalp, the eyebrows, and the face, 
in which minute glistening whitish points result, compared by Brocq to 
the lesions produced by destruction of the hair-papilla in electrolysis. 
It is possible that these lesions are due to the cause suggested for the 
first group. 

(c) False alopecia areata (" pseudo-pelade " of French writers). In 
these cases the scalp about one or several hair-follicles becomes tumid 
and reddened. The hair is loosened in its pouch, and, whether it fall 
spontaneously or be removed by epilation, it is not replaced by another. 
The scalp is left whitish, smooth, ivory-like, depressed, thinned, and 
apparently atrophied, without trace of the new-formed downy hairs 
often noticed in alopecia areata. As distinguished from the last-named 
disorder, the advance of the patch may be in irregular lines rather than 
by extension of the rounded or oval circles formed in alopecia areata. 
Minute islets of alopecia exhibit the outlying evidences of disease. 

(d) Cicatricial alopecias with a punctiform appearance of the plaque. 
Here there is an inflammatory involvement of the follicle and peri- 
follicular tissue, with redness of this special region that disappears after 
atrophy has occurred. The sequel is a depressed whitish cicatriform 
tissue, marked here and there with pinhead-sized, reddish points where 
the circumpilary exudation is still in activity. 

(e) Quinquaud's Disease 1 (Acn6 Decalvante of Pailler and Robert). 
Here miliary abscesses, punctiform, pinhead-sized and larger, involve 
the follicle. The hair originally piercing these suppurative lesions is 
loosened and falls, after which the follicle atrophies and the hair is no 

1 Bull, de la Soc. med. des Hop., 1888. 






ALOPECIA. 519 

longer produced. The scalp is left dead-white, thinned, depressed, 
atrophied, and cicatriform, in patches as large as those visible in alopecia 
areata, but often irregular in outline. The follicles remain distinct and 
are not fused into a mass ; they resemble the distribution of the lesions 
in coccogenous sycosis. In some instances this special follicular alopecia 
and scarring have progressed without suppurative involvement of the 
follicle, and in cases without any signs of inflammation. 

(/) Lupoid sycosis (Brocq) ; Ulerythema sycosiforme (Unna). 
Special attention should be directed to this affection, as it is of great 
importance to distinguish it from the more common variety of cocco- 
genous sycosis, which it strongly resembles. 

This disease chiefly affects the male beard (a region more accessible 
than the scalp to the fingers), and its early symptoms are well-nigh 
indistinguishable from those of sycosis of the type named above. 
There are large and small, well-defined, follicular and perifollicular 
pustules, with redness, infiltration of the derma, scales, crusts, and 
characteristic deformity ; but as the disease progresses the hairs are 
removed from the whole or a large part of the involved area, and there 
is left, after a relatively long period, occasionally suddenly produced, 
a cicatricial or keloid-like surface, which may be smooth or highly 
irregular. 

In mild cases there is left a reticulum of narrow, scar-like, whitish 
lines, irregularly radiating over the surface, giving to the eye and touch 
the suggestion that they are depressed below the general level of equally 
irregular areas of the bearded chin or cheek. These areas may or may 
not be provided with hairs ; in the former event the growth is stunted 
by the contracture of the encircling atrophy, where a species of fibrosis 
has occurred. 

In severer cases there is left a more generalized cicatriform tissue, 
for the most part unprovided with hairy filaments. The process may 
be such as to interfere with the movements of the lips in articulation 
and mastication. These parts, for months after the disease has accom- 
plished its evolution, are somewhat reddened. In both forms the cen- 
trifugal direction of the morbid process has been observed. 

(g) In a last group are placed a few ill-defined cicatricial alopecias, 
beginning often with perifollicular, rather than follicular, pustulation, 
accompanied by redness of the affected part and the eventual formation 
of peculiarly persistent crusts. When these crusts fall a reddish, 
slightly scaly surface is left, followed by cicatricial atrophy and a patch 
with distorted and friable or fairly vigorous hairs, surrounded by an 
elevated rim. There is little definition ; distinct patches of the disease 
are rarely seen. It more often affects the beard, and may be symmet- 
rical. It may coexist in the same subject with acne-keloid, atrophic 
acne, and other varieties of that disorder, with which it is unquestionably 
related. 

It will be seen from the foregoing that there has been recognized a 
series of interesting and important affections of the hairy parts, as yet 
not distinctly differentiated each from the other and the series from all 
others. Some of them may be found eventually to be varieties of lupus 



520 ATROPHIES. 

erythematosus ; others, of tuberculous infection of the scalp. Kaposi's 
dermatitis papillaris capillitii is without question to be recognized in 
some of the descriptions given. A few may be rare localized gumma- 
tous changes produced by syphilis. All are best treated with corrosive- 
sublimate lotions, 1 part of sublimate to 400 ; boric acid lotions and 
powders ; and salves containing mercury, sulphur, and iodine. Galvano- 
cauterization of the pustules and inflammatory points has successfully 
been employed in some of the reported cases. All these disorders are 
well managed if treated in accordance with the principles suggested in 
the chapter on Sycosis. 

KELOID-ACNE. 

(Acne Keloidienne, Dermatitis Papillaris Capillitii, Pian 

Ruboide [Alibert].) 

Under this title Kaposi describes a disorder characterized by pinhead- 
sized, isolated or confluent elevations of the skin-surface, with inter- 
spersed pustules, which finally form cicatriform plaques over which the 
hairs are either clustered in tufts or are totally absent. The pilary 
filaments are atrophied yet firmly fixed in their follicles, and they 
suffer elongation or fracture before withdrawal. The disease is encoun- 
tered chiefly upon the nucha, the occiput, and the vertex. Papil- 
lomatous vegetations, crust-covered, hemorrhagic, and with a foul- 
smelling secretion, sometimes form, and eventually retract into a scle- 
rotic tissue. 

One of us has described typical cases of this disorder, 1 each of which 
concluded with the production of a keloid-like, cicatriform, irregularly 
shaped but circumscribed elevation of the surface. This feature is that 
by which it specially differs from all other sycosiform disorders; The 
disease seems to be due fully as much to inflammatory processes in the 
subcutaneous tissue between the unyielding pericranium and the thick 
scalp as in the derma proper, and therefore it is not, strictly speaking, 
a dermatitis. Puncture, for example, of one of the pinhead-sized 
pustules commonly gives exit to the usual quantity of pus ; but pressure 
upon the scalp in the periphery will at once be followed by the appear- 
ance of a still larger quantity of similar pus which evidently is expressed 
from a circumscribed subcutaneous abscess. When by such pressure 
the abscess-cavity is emptied it slowly fills with venous blood and 
produces a firm, semisolid elevation of the surface that subsequently 
undergoes sclerosis, and the starved hairs above behave in the manner 
described by Kaposi. The papules and plaques are formed in a sim- 
ilar way by the abundant supply of venous blood. The case of one 
of the patients presented at the clinic had been erroneously diagnosti- 
cated by a surgeon as aneurismal in character. Puncture of all such 
semisolid, cicatriform lesions is invariably followed by oozing of venous 
blood in abundance. The disease is chronic in character, is particu- 
larly liable to relapse in crops of pilary or peripilary pustules and 
papules, and it extends from nucha to vertex, avoiding the frontal and 

1 Jour. Cutan. and Ven. Dis., vol. i., No. 2, p. 33. 



ULERYTHEMA APHRYOGENES. 521 

temporal regions. Over the bald or partially bald keloid-like eleva- 
tions there is seen, in some cases, a species of seborrhoea in the form 
of more or less adherent, fatty crusts, with occasional characteristic 
tufts of hairs. 

The disease seems to owe its special character to the anatomical 
peculiarities of its location. It occurs preferably at the points where 
the venous supply of the scalp is not only greatest, but where it is also 
in most direct connection with the large vessels beneath, and where an 
inflammatory process in the derma or subcutaneous tissues invites with 
readiness a pathological afflux of blood. Such a focus, limited beneath 
by the dense calvarium, and above by the relatively thick scalp, 
readily undergoes organization and sclerosis, the subsequent behavior 
of the hairs and hair-follicles being an accident of the process. 

According to Besnier and Doyon, the disorder is a papillomatous 
development, likely to occur in this region of the scalp as a sequel of 
epilating, cicatricial (keloid) acne, eczema, or traumatism. 

Sangster (in a paper read before the International Medical Congress 
in London, 1881) described a pigeon's-egg-sized tumor of the scalp, 
that Kaposi, who was present, recognized as a case of dermatitis papil- 
laris capillitii. 

Treatment. — The method of treatment to be employed in this rare 
disease can scarcely be described as established. The affected surfaces 
are first freed from subcutaneous abscesses by puncture and expression 
of the contents. Then the patch is washed with hot carbolized water, 
dusted with boric acid or iodoform, and a compress, moistened with 
an antiseptic solution, such as corrosive-sublimate wash, is firmly 
bandaged over the part. When pathological fluids no longer form 
under the scalp the patch is best epilated and anointed with a salve 
containing 1 drachm (4.) of precipitated sulphur to the ounce (32.) of 
scented vaselin, which salve may also be kept constantly over the part. 
When crusts form they may be removed by shampooing with green 
soap. 

Internal treatment is suggested by the constitutional condition of 
the patient, and it should often include cod-liver oil, the ferruginous 
tonics, and a roborant regimen. 

ULERYTHEMA APHRYOGENES. 

This affection was first described by Taenzer in Unna's clinic. 
According to Unna, it occurs most frequently in blondes, is usually 
located in the eyebrows, from which it may spread to adjacent parts, 
including the scalp, or it may appear on the extensor surfaces of the 
upper arms. The condition may be no more than a persistent ery- 
thema, with small, elevated, horny papules at the mouths of the hair- 
follicles. The hairs are finer than normal and usually are broken off 
close to the surface. The disease may persist for years without further 
change, but in the severer forms atrophy, both follicular and interfol- 
licular, results, so that small, depressed scars are surrounded by, or 
commingled with, the hypersemic areas. The resulting alopecia is per- 
manent and may be very marked, especially on the eyebrows. 



522 ATROPHIES. 

ATROPHIA PILORUM PROPRIA. 

Atrophy of the hair may be either symptomatic or idiopathic. Illus- 
trations of the first-named condition are observed in phthisis, syphilis, 
seborrhcea, ringworm of the scalp, and in almost all general diseases in- 
terfering with the nutrition of the pilary growth. The filaments then 
become dry, lustreless, friable in both longitudinal and transverse 
diameters, and diminished in each dimension. 

There are several recognized forms of idiopathic atrophy of the hair. 
One of these forms exists in those long hairs which are seen to be ir- 
regularly thinned or flattened in the shaft, and split at the point into 
two or more recurving fibrillar, a condition noted, for the most part, in 
few hairs scattered among those of full development and vigor. This 
especially localized atrophy seems to be peculiar to one or more follicles 
merely; and is analogous to the condition in which there appears 
among the vigorous pigmented hairs of early life a single blanched 
filament. 

FRAGILITAS OMNIUM. 

Under this title a number of odd disorders, due to atrophy, and pro- 
ducing fragility, splitting, or curling in abnormal directions of pilary 
filaments, have been described by authors. 

" Undescribed form of Atrophy of the Hair of the Beard " 
of Duhring. 1 In this affection, either at the bulb or at a variable dis- 
tance, from it but within the follicle, there is fission of the hair-fila- 
ments into from two to four stalks with coincident atrophy of the bulb 
itself, and consequent irritation of the surface. Duhring's patient ex- 
hibited to a marked degree the species of hypochondriasis to which the 
subjects of disease of the hair seem specially prone. This disorder 
is not induced by a parasite. 

In 1887 a gentleman applied for advice who was in a fair condition 
of general health, but the hairs of whose beard exhibited the symptoms 
described and figured by Duhring. Photo-micrographs of specimens of 
these hairs show clearly that in every case the fission of the filament 
extended completely to the base of the follicle and produced there irri- 
tation. The hairs over several square inches of surface were thus 
uniformly affected, normal filaments being in such areas absent. The 
interfollicular spaces, however, seemed to be abnormally widened, as 
though in these areas such normal hairs might have fallen in conse- 
quence of a species of alopecia. The disease was much more strongly 
marked on the chin than on the cheeks or the upper lip. The curl- 
ing of some of the splinters was complete and characteristic. 

TRICHORRHEXIS NODOSA. 

(Trichoptilosis [Devergie], Nodositas Crinium.) 

_ Trichorrhexis nodosa, first described by Wilks and Beigel, is a con- 
dition in which the hairs display nodose swellings along the shaft at 
irregular distances, the beard and moustache being most often affected, 

1 Arner. Jour. Med. Sci., July, 1878. 



TRICHORRHEXIS NODOSA. 



523 



though rarely there is involvement also of the hairs of the scalp, the 
axillae, and the pubes. The hairs are brittle, and fracture usually oc- 
curs through the node, leaving a broom-like mass of filaments project- 




Trichorrhexis nodosa. (After Schwimmer.) 



ing there, while the internodular portions of the shaft appear normal 
save for enlargement of the medulla (Fig. 62). The fragility of the 
hair at the centre of the node seems to depend upon the tension and 
consequent fissure of the cortical layer, which is greatest at that point. 



524 ATROPHIES. 

The hair-bulbs are firmly adherent in their follicles. In a form of this 
disease common among the women of Constantinople Hodara discov- 
ered a bacillus, with pure cultures of which he reproduced the disease 
in a woman's hair. It is probable that the condition is always caused 
by a definite micro-organism. 

According to Brocq, trichorrhexis nodosa is not produced by spe- 
cific bacteria upon the shafts of the hair : though Spiegler l reports 
that when of occurrence upon the beard, bacilli and cocci, probably 
identical with those described by Hodara, are found in heaps, not 
merely on the shafts of the hairs, but in the walls and enclosed bulb of 
the hair-crypts. 

Treatment is not satisfactory, as a rule. Sabouraud highly recom- 
mends daily applications of the following : 



R Hydrarg. bichlorid., gr. iij ; 

Acid, tartaric, gr. viij ; 

Resorcin., gr. xv-xxx; 1.00 to 2 



20 
40 
00 

00 



M. 



Shaving has been followed in some of Kaposi's cases by good results ; 
while Roeser 2 advocates the local employment of dilute tincture of 
cantharides. 

Monilethrix (Ringelhaaren ; Moniliform, Beaded Hairs ; Pili 
Annulati ; Ft., Aplasie Moniliforme Intermittente) is a somewhat rare 
condition first observed by Smith (as described below), and since by 
numbers of others, including Luce, Anderson, Crocker, Lesser, and 
Behrend. A patient affected with this disease was exhibited at the 
International Congress of Dermatology held in London in 1896. Like 
the forms of fragility described above, the hairs are peculiar in exhibit- 
ing along the shaft a succession of rings or nodes, between which are 
narrower portions of the shaft, of a color lighter than that of the pig- 
mented nodular or annular portions. The result is a characteristic 
checkered appearance of the hairs. Fracture always occurs in the 
internodular part, the fractured extremity having a characteristic brush- 
like stump. These conditions are evidently due to atrophic changes in 
the internodular parts, with better development in the pigmented and 
thicker portions of the shaft, the whole being due to nutritive changes 
which Virchow explains as due to a periodic aplasia of the hair-papilla. 
The obvious symptoms are clearly the result of a profound process, 
originating probably in the trophic nerves. 

Nodose Swellings of the shafts of the hair. Smith, 3 of Dublin, 
first reported a case of this disorder. Photo-micrographs of some of 
the hairs from this patient exhibit no fragility at the nodes, which 
beginning near the scalp are regularly displayed along the shaft, the 
fracture being always internodular. The spherical swellings along the 
shaft are also pigmented in a brown hue, and these pigmented nodose 
swellings, contrasting with the non -pigmented color of the unaffected 

1 Arch. f. Derm. u. Syph., Bd. xii., Heft 1. 

2 Annal. de Derm, et de Syph., 1877-1878, pp. 185 et seq. 

3 Brit. Med. Jour., May 1, 1880. 



LEPOTHRIX. 525 

portions of the shaft, give the hairs a singularly " checkered " appear- 
ance. No parasite is discernible in any of the specimens. 

Expansions and Fissures of the Hairs. — Michelson, under 
this title, discusses the abnormalities of the pilary system, instances of 
which are cited above, and he concludes as to the most of them that 
they are not separate diseases, but are expressions of an abnormal dry- 
ness and brittleness of the hairs due to atrophy. Cases of broom-like 
Assuring and division of the shaft into larger longitudinal splinters he 
regards as equivalent processes, both beginning by a cuticular loss and 
often merging into each other. 

This view may be sound with regard to a number of these rare affec- 
tions ; but even a superficial examination of the longitudinal splinters 
shown in Duhring's and the authors' cases reveals the fact that the 
shaft represented by the sum of all its splinters is greater than that 
of the average hair in diameter and circumference. Even the naked 
eye can recognize this fact. The distention of the epilating-forceps in 
seizing a single hair, in the case of our patient, was equivalent to the 
grasping of as many sound filaments as are represented by splinters. 

The therapy of these cases is not well determined. Michelson be- 
lieves shaving to be useless, and he recommends systematic shampoo- 
ing and oiling. Arsenic internally is worth trying in all cases in 
which it is not contraindicated. 

LEPOTHRIX. 

(Gr. tenog, scale ; fyu'f, hair.) 

(Trichomycosis Nodosa.) 

This disorder, first described in 1869 by Paxton, and since recog- 
nized by Patteson, Pick, Babes, Barthelemy, and others, affects 
the hairs, chiefly of the axillae and the genital regions. The fila- 
ments are dry, brittle, roughened, and loosened in their follicles. 
Under the microscope the shaft is seen to be either for a great part or for 
the entire length ensheathed in a concretion which may here and there 
be interrupted by furrows — a diffuse form of the affection. In a 
nodose form there are irregularly placed spherical masses, isolated 
from one another and more numerous toward the point than near the 
implanted extremity of the shaft. Crocker describes also circular and 
well-defined masses, lying upon but not surrounding the shaft, three 
times the diameter of the shaft, and containing fibres of the cortex 
that had been split by the concretion. The fracture may be clean 
or be brush-shaped. The nodular masses are exceedingly well attached 
to the shaft, and reddish brown to blackish in shade. At times red- 
dish sweat of the axillae, due to micrococci, has been a coincident 
symptom. 

The nodes are found to be made up of chains of spherical or of 
elliptical micrococci, which penetrate the cortical layers of the hair 
with ease in regions of considerable moisture and sweat. The micro- 
organisms at first obtain access by minute separations of the cuticle of 
the hair, and they eventually penetrate more deeply, breaking up the 



526 ATROPHIES. 

cortical portions. While thus multiplying, a homogeneous substance, 
similar to the chitine by which the louse fastens its eggs to the hair, 
forms the bulk of the concretion in which the colonies of cocci are 
lodged. 

The Treatment is by shaving and external applications of mercuric 
chloride (1 : 2000). 

PIEDRA. 

Piedra is a term descriptive of blackish and exceedingly firm nodes, 
partially or completely surrounding the hairs, and distributed without 
special order along any part of the shaft. The nodes are of the size 
of a pinhead, and, though occurring chiefly in the hairs of the head 
of women, have been seen also on the scalp and the beard of men. 
Desenne, Morris, Juhel-Renoy, and Lion have reported cases. The 
disease belongs to the group of hyphogenous disorders. The nodes are 
seen to consist of masses of spores with abundant mycelium, readily 
cultivated but never penetrating to the interior of the hair. The hair- 
bulb remains intact, and the disease is at once relieved by shaving or 
cutting the aifected filaments. It occurs chiefly in Cauca, Colombia, 
but has been recognized elsewhere. In the case of a young girl sent 
from the Chicago Eye and Ear Infirmary there were numerous jet- 
black, horny, and dense spherical masses attached to the hairs of the 
eyelashes of each lid of both eyes. 

BEIGEL'S DISEASE. 

(Chignon Fungus.) 

This affection is discovered upon false hairs, which exhibit on their 
shafts dirty-brownish nodes, due to masses of parasites. The fungus 
has not definitely been distinguished. The nodes are irregularly strung 
along the shaft of the hair. 

TINEA NODOSA. 

This disorder, first discovered by Morris and Cheadle, affects the 
hairs of the beard or the moustache. The nodular concretions, which 
give the hair an irregular outline, are shown to be made up of fungus- 
spores a little smaller than those of tinea trichophytina. The hairs are 
brittle and break or split. 

The Treatment is by shaving or clipping, with the application of 
parasiticides. 

ATROPHIA UNGUIS. 

{Fr., Onychatrophy.) 

Atrophy of the nails may be a congenital or an acquired condition, 
in which there is deficient or defective production of nail-substance. 
The congenital forms are usually observed when the digits are poorly 
developed, and there is at the same time a deficiency of the pilary 
growth. The nails may be absent in these cases, or merely be tardy 



ATROPHIA UNGUIS. 527 

of evolution ; occasionally they are seen, especially upon rudimentary 
or coalesced digits, in defective and distorted shapes. 

Nicolle and Halipre l and C. J. White 2 report interesting cases of 
dystrophic disorders of the nails and hair extending through several 
generations of the same family. In the French cases the condition was 
seen in thirty-six individuals in six generations. One of those affected 
was an idiot, another a subject of hysteria, and another of feeble intel- 
lect. There were other evidences of a family tendency to mental and 
nervous deterioration. The hairs in the affected individuals were 
scanty, short, thin, light-colored, friable, and easily epilated. The 
most marked symptoms, hoAvever, were in the nails, which showed vari- 
ous grades of hypertrophy and atrophy, with periungual changes of an 
inflammatory type, due probably to injury or secondary infection. 

In acquired atrophy the nail may be changed either in color, bulk, 
elasticity, firmness, shape, or position. Thus, the nail may be ex- 
panded and thin, narrow and acuminate, friable, furrowed, laminated, 
ridged, or otherwise distorted. It may uniformly or partially be 
lustreless, or singularly striped, or even irregularly speckled. 

These changes in various combinations result chiefly from trauma- 
tism, such injuries, for example, as are common to the toes in the boot 
or shoe, and to the fingers when actively employed in the trades. 
Excessive heat and cold and constant maceration in chemical solutions 
(as among photographers, dyers, and druggists) often operate injuri- 
ously upon the nail-tissue. The inflammatory dermatoses, eczema, 
psoriasis, and the like are frequent causes of atrophy and dystrophy of 
the nail. All serious disturbances of systemic nutrition, as are inci- 
dent to prolonged fevers, surgical accidents, tuberculosis, ataxic con- 
ditions, etc., interfere visibly with the nutrition and development of 
the nail. Syphilitic changes in the nail are commonly due to gumma- 
tous involvement of the matrix. Severe ulceration of the matrix is 
often followed by atrophic or other distorted conditions of the nail- 
substance. 

The Treatment of these conditions is largely that of the disorders 
upon which they depend. The nails may often with advantage be 
scraped to a desired smoothness, well trimmed, shampooed vigorously 
with green soap, employing this also over the adjacent soft parts of 
the digit, soaked in unguents, and then protected by wax, leather stalls, 
etc., from injurious contacts. Arsenic internally is said to be useful in 
some affections of this kind. 

Achromia Unguium (Albugo, " White Spots "; Fr. } Decolor- 
ization des Ongles). — This is a peculiar condition found in young 
and healthy subjects who exhibit a number of dead-white macules on 
j one or several of the nails, usually of the fingers. Morison, of Balti- 
more, reported to the American Dermatological Association 3 a case 
illustrated with a portrait, in which linear striae, transverse to the long 
axis of the digit, appeared on the fingers. Since then we have observed 

1 Annal. de Derm, et de Syph., August and September, 1895. 

2 Jour. Cutan. and Gen.-Urin. Dis., June, 1896. 

3 Vierteljahr. f. Derm. u. Syph., 1888, vol. xv. 



528 ATROPHIES. 

a group of similar cases of the disease, one the subject of a portrait in 
oil, in which this condition existed. In all of our patients, young 
people of each sex, the fingers of the two hands were capriciously 
selected for exhibition of the peculiarity. It has been supposed that 
the presence of air in the nail-substance is responsible for the appear- 
ance. The affection is probably a trophoneurosis due" to nutritional 
changes in the nail-matrix. 

ATROPHIA CUTIS. 

(Gr. a, privative, and roofi}, nutrition. ) 

The skin and its appendages, in common with other organs of the 
body, may suffer from atrophy, either idiopathic or symptomatic in 
character, and general or partial in extent. It may result from either 
quantitative or qualitative retrogressive changes, losing thus its nor- 
mal dimensions, either from wasting of one or of all its normal elements, 
or from degenerative changes in the latter, or from their complete and 
final disappearance. These changes may be simultaneous. They are 
usually effected slowly, and the results are persistent. They are fre- 
quent concomitants of a long list of other pathological alterations ; 
usually, however, the atrophy succeeds other morbid changes. 

ATROPHIA SENILIS. 

This is the frequently recognized cutaneous degeneration peculiar to 
old age. The skin becomes colored in various shades of brown, either 
uniformly or in tolerably distinct maculations over the face, the dorsum 
of the hands, the genitalia and the anus, and the lower extremities. 

The skin is seamed with furrows and wrinkles, is very dry, may 
desquamate slightly, and, losing the cushion of fat upon which it rested 
in earlier life, is either readily raised from the subcutaneous structures 
or depends from them in loose folds. The hairs on the affected areas 
may fall or may undergo regressive changes to the lanugo-type. Pea- 
to finger-nail-sized verruciform, dirty-yellowish accumulations of epi- 
dermis become visible, often in numbers on the face and elsewhere, 
or there may be small pendulous shrivelled pouches representing fibro- 
mata that have disappeared. These epithelial growths, especially when 
irritated, are not infrequently the beginning of malignant epithelioma. 

In quantitative senile atrophy the pathological changes include a 
general thinning of both corium and epidermis, as a result of which 
their characteristic interdigitations largely disappear ; an increased 
pigmentation in the rete ; a shortening of the hair-follicles ; a dilatation 
of the sebaceous and coil-glands, the mouths of which often become 
blocked with epithelial detritus ; the obliteration of some vessels and 
the dilatation of others ; and the disappearance of the fat-cells from the 
meshes of the connective tissue. 

In degenerative atrophy there may be fatty, amyloid, vitreous, and 
other changes of one or of several elements of the skin. Neumann 
described a senile atrophy with a granular degeneration and a vitreous 
swelling of the connective-tissue fibres. Schmidt, Reizenstein, and 



ATROPHIA CUTIS. 529 

Unna think these changes due to a peculiar arrangement of the elastic 
fibres and their partial degeneration into elacin, or, in combination 
with the collagen, into collastin and coleascin (Unna). These 
changes in the elastic fibres are manifested through the peculiar stain- 
ing qualities of the latter, and in the light of modern technique are 
exceedingly interesting, as they occur not only in atrophy, but also in 
other cutaneous disorders. 

Senile atrophy cannot be remedied, but it may often be prevented 
or postponed by securing for the skin and for all the tissues of the 
body the best possible nutrition and hygiene, and by protecting the 
skin from exposure to cold and other harmful influences. The nutri- 
tion of the skin may often be improved by the proper use of bran- or 
salt-baths, massage, electricity, or inunctions of oil. Cod-liver oil or 
other fats may usually be added to the diet with advantage. Care 
must be taken to protect all warty and other epithelial growths from 
irritation, with a view to the prevention of malignant changes. 

ATROPHIA MACULOSA ET STRIATA. 

(Fr., Vergetures.) 

These forms of cutaneous atrophy may conveniently be divided into 
the so-called idiopathic and the symptomatic. 

Partial Idiopathic Atrophy of the skin occurs most frequently in 
linear cicatriform striae or streaks (a centimetre or more in length) de- 
veloped chiefly about the hips, buttocks, and upper portion of the thighs 
in persons of both sexes of adult years. Less frequently these striae 
' are observed upon the neck, the trunk, and the extremities. They are 
insidious of development, indelibly persistent, and appear as sensibly 
I thinned, glistening, and often depressed lines or furrows, having a 
whitish hue, with an occasional blending of a very delicate purplish 
j tint. They are usually multiple, and at times abundantly displayed, 
running in various curves, for the most part at angles with the long 
axis of the body. They occasion, as a rule, no subjective sensation. 

Much more rarely the atrophic areas occur in macular patches. 
\ The lesions are then fewer, more isolated, and are discovered more 
i frequently upon the extremities, but also upon the trunk, varying in 
■j size from that of a coifee-bean to that of a chestnut. This form of 
' atrophy often succeeds either an erythematous or a pigmented condi- 
|j tion, which very slowly changes until there is formed a dead-white, 
I round or oval, often insensitive patch, more or less depressed, resem- 
1 bling coarsely a vaccine cicatrix. These areas usually show partial or 
complete alopecia. 

8F6re and Quemonne l have described two singular cases of the disease 
observed in Charcot's clinic. In one of these cases appeared minute, 
whitish, elongated cicatrices, about which there was a marked pigmen- 
tation of the skin. They were abundant in the lumbar region. In a 
second case brownish lines appeared over the breast of an unmarried 
, woman, that gradually grew paler while others appeared over the skin 

1 Le Progres med., Oct. 29, 1881, p. 837. 
34 



530 ATROPHIES. 

of the throat. Those lines which were recent had a brownish or a 
bluish-red color ; others were of a dead- white hue ; some appeared over 
the lumbar region and the upper part of the buttocks ; but there was 
none over the belly, the groins, or the thighs. In both cases the regions 
attacked were those in which there was no suspicion that the vergetures 
resulted from overdistention of the skin. 

These lesions are to be distinguished from sequels of scleroderma, 
syphilis, and other diseases capable of leaving atrophic areas. A pre- 
vious history of such pathological conditions would usually be obtain- 
able. In the cases in which there is precedent telangiectasis, hyperemia, 
or marked pigmentation of the spot, the diagnosis, as several authors 
suggest, is attended with some difficulty. 

Diffuse Idiopathic Atrophy of the skin (General Idiopathic Cu- 
taneous Atrophy, Atrophia Cutis Universalis, Progressive 
Idiopathic Atrophy) is usually of progressive type. In these cases 
the integument over large areas, such as that covering an entire limb 
or the trunk, becomes thin, flaccid, dry, scaly, unprovided with fat, 
and brownish or dead whitish in hue. Puncta, striae, and plaques, 
reddish blue or reddish brown or even purplish in color, are to be 
seen marbling the surface and occasionally leaving after disappearance 
a decided pigmentation. The process slowly advances over the regions 
aifected. 

Bronson has recorded a very unusual and interesting case of this 
form of atrophy, with reference to the principal cases so far reported. 1 
Elliott 2 and Fordyce 3 have reported each a case of symmetrical and 
extensive atrophy, in which the progressing change was preceded by 
the occurrence of a zone of capillary dilatation or cyanosis. 

Partial Symptomatic Atrophy of the skin in its simplest form may 
result from traumatism (the persistent marks sometimes left on the 
skin, for example, by a lash with a whip, insufficient to wound the 
epidermis but capable of injuring the deeper elastic tissue) ; or from the 
slow pressure of tumors (ovarian, uterine, mesenteric, etc.), by which 
the skin is distended. The well-known results of the stretching of the 
skin in a first pregnancy conducted to term are linear atrophies, at first 
of a violet tint, and later of a dead-whitish hue, that are indistinguish- 
able, both clinically and pathologically, from idiopathic lesions of 
similar aspect. These atrophies are occasionally seen over the belly 
and thighs of male subjects with a protuberant abdomen. Small atrophic 
scars result frequently from the mechanical pressure of inflammatory 
and other infiltrations seen in lupus, syphilis, leprosy, and other diseases. 
Partial symptomatic atrophy, with degeneration of the cutaneous ele- 
ments (fatty, lardaceous, waxy, etc.), is a sequel common to a long list 
of cutaneous affections. 

Etiology and Pathology. — The causes of idiopathic atrophy are 
not known. It is generally considered a trophoneurosis, with possibly 
malnutrition as a predisposing cause. Elliott's and Fordyce's cases 
(noted above) would suggest an origin in some circulatory disturbance. 

1 Jour. Cutan. and Gen.-Urin. Dis., January, 1895. 

2 Ibid., April, 1895. 
a Ibid., May, 1897. 



GLOSSY SKIN. 531 

The histological changes are those of simple atrophy of the tissues 
without degenerative changes. 

The causes of the symptomatic atrophies are obvious. Histological 
examination shows in some cases simple tearing and separation of 
elements, especially of the elastic fibres ; in others an atrophy of the 
corium and epidermis. Unna describes a pressure-atrophy, in which 
the elastic tissue is torn or displaced to the margins of the area, and 
an atrophy due to tension which differs from the preceding in that some 
small fibres of elastin still are visible together with other fibres that 
have undergone a degeneration into "elacin," in this respect resembling 
senile degeneration. 

The Treatment is prophylactic as in senile atrophy. 

GLOSSY SKIN. 

(Ateophodeemia JSTeueiticum.) 

The " glossy fingers " described by Sir James Paget, 1 Gull, Mitchell, 
and others, are tapering, smooth, hairless, unwrinkled, glossy, pink, 
and ruddy or blotched, as if with permanent chilblains. One or several 
fingers are affected. The condition is associated with neuralgia or 
nervous impairment indicated by abnormal sensations, as of heat or 
intense burning. There is usually, however, a precedent or subsequent 
; neuralgic pain, with incurvation of the nails and at times a heaping 
I up of epidermal masses beneath the free border of the nail. In conse- 
i quence of retraction of the skin over the distal phalanges the terminal 
extremity of the digit appears thinned and drawn away from the nail- 
bed. 

The complications of this condition are changes in the sebaceous 
glands and the coil-glands, loss of hair over the phalanges, excoria- 
tions, and in severe cases ulceration. 

This disorder may be associated with grave systemic states, such as 
lepra, or with gout and rheumatism. It is found also in those in whom 
for any reason the circulation is feeble and there has been exposure of 
the extremities to severe cold. It has likewise been noted as the result 

Sof centric and peripheral changes in the nervous system. In some 
cases the cause is recognized as a neuritis ; in other cases it may more 
properly be classed with the trophoneuroses of the skin. The rela- 
I tions of this and several symmetrical disorders of the hands and feet 
! to the so-called " perforating ulcer of the foot," " asphyxia " of the 
i extremities, " symmetrical gangrene" of the extremities, and so-called 
i" dying of the fingers," all manifestly trophoneurotic affections (see the 
'chapter on this subject), have not yet satisfactorily been established. 

Blanching Ateophy of the Sein. — This peculiar degeneration 
of the integument is characterized by an unnatural whiteness or pallor 
i of the skin-surface, with considerable tension and tenuity of the epider- 
imis, usually limited to the extremities (the arms and palmar faces and 
i the thighs and legs and plantar faces); moderate exfoliation occurs, 
and the latter, in connection with the tension to which the skin is 

1 Med. Times and Gazette, March 24, 1864. 



532 ATROPHIES. 

subjected, is responsible for more or less painful subjective sensations. 
The disorder is chronic in its course, and it may originate in infancy. 
This condition is occasionally illustrated by persons affected with a 
sensori-motor paralysis of one limb, when the muscles waste and the 
fat-cells persist, multiply, or wholly disappear. The .skin of such 
limbs, wholly or in patches, becomes unnaturally soft and delicate, and 
undergoes a loss of pigment and hairs, at the same time that its bulk 
actually diminishes. The nails may participate in the process. In 
other cases of trophic disturbance the skin shrivels and assumes, instead 
of a whitish, a yellowish or yellowish-gray tinge. 

MULTIPLE BENIGN TUMOR-LIKE NEW-GROWTHS OF THE SKIN. 

Under this title Schweninger and Buzzi 1 describe and figure lesions 
occurring chiefly on the back, but also on the arms and the chin of a 
married woman, twenty-nine years of age. These lesions were bean- 
to coin-sized, bluish-white and slate-tinted formations, with delicate 
telangiectases over the surface of some. By pressure most of them 
could be forced into a shallow pit in the underlying tissue, the tumor 
returning like a ventral hernia after removal of the pressure. The 
larger seemed to spring from the smaller lesions, and as they increased 
in age became flatter, less white, harder, and less compressible. They 
produced no subjective sensations and in no way interfered with the 
general health of the patient. The vigorous treatment adopted seemed 
to have but little effect on the growths. 

Under the microscope sections of the excised skin showed that 
elastic fibres were in every instance wholly wanting in the affected 
portions, nor were there signs of remnants or of degeneration-products 
of these elements. It was assumed that there had been in each locality 
a retraction of the elastic tissue, and that the resulting disease was due 
to a disturbance of the static balance, the overgrowth developing until 
the equilibrium was established. A growth of new and young cells 
was visible about the adventitia of the vessels and most of the acces- 
sory organs of the skin. 

KRAUROSIS VULVAE. 

Breisky, 2 in Austria, and Heitzmann and others 3 in America, have 
described a condition of the vulva in women, affecting particularly the 
labia minora, the preputium clitoridis, and the vestibulum, in which 
there occurs a peculiar shrinking, shrivelling, or atrophic change. The 
labia minora in some cases wholly disappear, shallow furrows taking 
their place. The clitoris becomes hidden from view and may be rep- 
resented by a minute depression in the membrane. The integument 
covering this thinned or atrophied tissue is whitish, thickened, rough- 
ened, and dry, while the surrounding parts are glossv, reddish-gray 
or pallid in hue. In many cases the atrophic changes are preceded by 

1 Internat. Atlas of Kare Skin-diseases, 1890-1891, v. 
s Zeitschrift f. Heilkunde, Prag u. Leipzig, March, 1895. 

3 Cf. Baldy and Williams, Amer. Jour. Med. Sci., 1899, p. 528, with a review of 
the literature. 



PLATE XIV. 





7 " itfiHteirlk55& 



Malum Perforans Pedis, with Symmetrical Keratoma 
of the Palms and Soles. 

(From a water-color sketch of one of the author's patients.) 



PERFORATING ULCER OF THE FOOT. 533 

a period of congestion and intense pruritus, burning, or hyperesthesia. 
These subjective sensations usually disappear in the later stages of the 
disease. Women of all ages, from nineteen to fifty, suffer from the 
disorder, irrespective of coitus and pregnancy. 

The study of well-marked instances of this disorder indicates 
that for the present further investigation must be made before the 
identity of the disease can be accepted or its nosological position be 
established. The life-history of some of the affected patients must 
be had in order to gain a complete knowledge of the morbid condi- 
tion. In one patient the resemblance was very striking to certain 
indolent epitheliomata of the penis, where a remarkable shrinking may 
at times be produced in consequence of metamorphosis of tissue. 

PERFORATING ULCER OF THE FOOT. 

(Malum Perforans Pedis. Fr., Mal Perforaxt du Pied.) 

This disorder, first named by Vesigne has been studied by Savory 
and Butlin, 1 Gasguel, 2 and others. The name is an unfortunate one, 
since many cases to be classed only in this category have neither ulcer- 
ative nor perforating symptoms. 

Symptoms. — The first symptom is a proliferating thickening of the 
epidermis like a corn, usually single, occasionally multiple, appearing 
over a point of pressure (first or fifth metatarso-phalangeal joint, etc.). 
Inflammation and suppuration proceed beneath this thickening, spread- 
ing first to the soft parts of the sole and perhaps to the bone itself. 
Gradually a sinus forms, reaching from the side of the corn to the 
deeper parts involved. Meantime the skin in the neighborhood be- 
comes greatly thickened, heaping itself especially about the sinus. 
The latter is sometimes surrounded by a mass of granulations. The 
ulcer which eventually forms is circular in outline, deep, and at times 
very destructive in its effects. 

Thus far the lesion might be supposed to be the result merely of a 
greatly irritated corn, but other phenomena exhibited in differing 
cases are quite inexplicable in this way. The nails are altered ; super- 
fluous hair grows on the dorsal surface of the foot and the skin of the 
involved extremity ; pigmentation, erythema, or eczema may occur ; 
and the parts may become affected with either anidrosis or hyperidrosis. 
The disease has been noted as the result of spinal injury, congelation, 
posterior spinal sclerosis, anaesthetic leprosy, alcoholic and diabetic 
neuritis, and, in animals, after section of the sciatic nerve, the etiolog- 
ical element in these diseases being degeneration of the nerve (except 
of the motor nerve) which supply the part. Among the concomitant 
symptoms ascribed to the same causes are anaesthesia, neuralgic and 
rheumatic pains, hyperidrosis, and coldness of the feet. 

In a group of cases of perforating ulcer of the foot there is gen- 
erally a symmetrical involvement of the entire sole or palm, either of 
both feet or of both hands and feet. The patients are often young 
adults. The palms when involved never exhibit the translucent, 

1 Medico-Chirnrgical Transactions, 1879, vol. lx. 

2 These de Paris, July, 1890 ; a resume of ninety-one collected cases. 



534 ATROPHIES. 

yellowish, wash-leather-like appearance of the same condition of the 
soles, but rather suggest the dry, scaly features of the palms in certain 
forms of erythematous eczema of these parts, but always without itch- 
ing, and with coincident plantar tylosis. The soles, however, present 
the typical appearance of callositas throughout the entire region, the 
callosity reaching somewhat upward over the heel, and in certain 
patients relatively sparing the instep. In some cases the nails are not 
involved. The feet are always as cold to the touch as in pernio. 

Pathology. —The disease is, without question, a trophoneurosis, and 
may be due to injury to a nerve-centre, as in tabes dorsalis ; to a nerve- 
trunk, as in syphilis or leprosy ; or to the terminal nerve. Of ninety- 
one cases collected by Gasguel, 1 there were in sixty-nine central and 
in eight peripheral nerve-lesions. Histological examination has shown 
destruction of the myelin and axis-cylinder of twigs of nerves supply- 
ing the affected parts. According to Savory and Butlin, the sensory 
and nutrient fibrils of the involved nerves degenerate in consequence 
of pressure exercised upon them, by increase of the endoneurium, the 
motor fibrils escaping owing to their large size and thicker medullary 
sheath, a view untenable for all cases. 

Diagnosis. — The diagnosis is between tuberculosis and simple cal- 
lositas, a distinction readily established by the evident neurotic phe- 
nomena seen in perforating disease of the foot. 

Treatment. — By curetting away all diseased tissue and putting the 
foot completely at rest the ulcer may be made to heal, but it usually 
reappears when the patient again tries to walk. Amputation of the 
toe and joint aifected avails little. It is not unusual even after ampu- 
tation of the foot for the disease to appear in the stump. A roborant 
treatment and mechanical devices to prevent the use of the foot are to 
be advised in most cases. 

The Prognosis is doubtful. 

MORVAN'S DISEASE. 

(Syringomyelia, Analgesic Paralysis with Whitlow. 
Fr. y Panaris Analgesique.) 

Morvan's disease is a paretic affection chiefly involving the upper 
extremities, accompanied by pain and producing a series of whitlows, 
affecting first one side of the body and then the other. 

Symptoms. — In this disorder the arm is commonly first involved, 
the approach of the disease being insidious and usually first noticed on 
account of the production of pain and some loss of nervous and mus- 
cular power. At times the first sign of involvement is the production 
of whitlows, which either early or late in every case are tolerably sure 
to appear. In other instances the disease first displays an analgesia 
similar to that occurring in some subjects of lepra, the attempt having 
been made to establish a relation between the two diseases. In time 
atrophy of the interosseous muscles, of the flexors of the wrist, and of 
the tissues forming the thenar and hypothenar eminences may result. 
The integument of the affected limb has a bluish or empurpled look; 

1 Loc. cit. 



AINHUM. 535 

it may be thinned or thickened, and the ^eat of fissures, vesicles, and 
bullae, as well as of the characteristic whitlows, which vary in number 
from two to four or six. Ulceration, extending as deeply as to the 
tendinous sheaths, may result, and, as a consequence of one or more of 
the changes described above, the phalanges may necrose and be sepa- 
rated from the hand. 

Trophic changes arise in connection with the disease, pointing for 
the most part to an origin in disturbances of the centric nervous system. 
Among these disturbances may be named : hyperidrosis ; diminution of, 
variability in, or complete absence of the reflexes ; visual changes ; con- 
tracture of the fingers ; and a general distortion of the hand. Scoliosis 
and arthritic complications have been recorded in a number of cases. 

The disease is usually protracted in its course, lasting in some cases 
for a quarter of a century. 

Etiology. — The affection may first develop in childhood and last 
until middle life and longer, though more often it is first noticed after the 
occurrence of puberty. Women are much less often affected than men. 
Traumatism, malaria, and rheumatism have all been cited as possible 
causes of the disease. Its exact etiology is obscure. 

Pathology. — Neuritis and thickening of the neurilemma have been 
discovered in the nerves distributed to the affected parts ; as also 
sclerosis of the posterior cornua and columns of the cord. The cavities 
recognized in the central canal, distended with fluid, are supposed to be 
due to absorption of gliomata. 

Diagnosis. — The recognition of a fully developed case of Morvan's 

disease is readily established by taking into consideration the paretic 

I symptoms present, the whitlows, and the perversions of sensation, 

I more particularly in appreciation of temperature-changes, pain, and 

i contact with foreign bodies. Attention has already been directed to the 

striking resemblance between certain phenomena of anaesthetic lepra and 

I those of both syringomyelia and Morvan's disease. With respect to 

i the diagnostic difference between the two last-named affections, it is 

claimed that in most cases of syringomyelia the sense of touch remains 

! unimpaired. The time, however, is probably not distant when the two 

will be recognized as slightly differing manifestations of the same 

; morbid state. Scleroderma and glossy fingers are to be differentiated 

\ by the special peculiarities of each. 

Treatment is to be conducted on the general principles, surgical and 
medical, relied upon for meeting the indications of each case. In gen- 
eral the hygienic and dietetic management of the patient with a highly 
roborant regimen is conducive to recovery. Many of the subjects of 
the disease have been reported as relieved or even wholly cured. 

AINHUM. 

(From a native term, meaning " to saw.") 

This disease was first described by Clark 1 and later by J. F. 
Da Silva Lima, 2 of Bahia, in Brazil, who collected a large number of 
cases. In a paper presented by him, which was read by one of us before 

1 Transactions Epiderm. Soc., 1860. 2 Arch, of Derm., 1880, p. 367. 



536 ATROPHIES. 

the American Dermatologioul Association, in 1880, the disease was 
described as affecting usually the little toe of negroes of Africa and 
Brazil. An indurated ring encircled the root of the digit, which pro- 
duced, finally, a deep, narrow circular depression, the latter deepening 
till the toe was strangulated, and finally, in the course of from five to 
ten years, completely detached. Meantime the volume of the digit was 
greatly increased by development of fatty tissue at the expense of the 
tendons, vascular elements, bones, and cartilages. This paper was 
accompanied by the presentation of a toe affected with ainhum ; and 
the specimen was referred to a committee, which after examination 
reported with a full description of the anatomical appearance of the 
specimen, that the constricting ring was probably produced artificially 
by tying a thin ligature around the toe, which, if not continuously 
encircling it, was worn at least for long periods of time. 

Duhring also has published the report of a case of ainhum in which 
microscopical examination was made by Wilde of a toe that was cast 
off from the foot of a negro in West Virginia. The pathologist came 
to the conclusion in this case also that the disease was essentially an 
inflammatory oedema produced by ligating the toe. 

Though the disease has since been studied by many competent 
observers its exact nature is still undetermined. Considering the fact 
that among superstitious races, especially the blacks, the most singular 
practices of self-mutilation are observed, it is possible that in some of 
these cases the toe is constricted by a ligature intentionally applied 
around it. That many of these cases occur independently of such 
intentional mutilation there can be no doubt when the observations of 
other competent observers are considered. Zambacho Pacha ! discusses 
at length the possible relation of the disease to leprosy. 

The probable relation of the disease to other trophoneuroses is well 
illustrated by a child presented at our clinic, a deaf mute who was an 
inmate of one of the public institutions founded for the care of that 
class of sufferers. The patient was twelve years of age, fairly well 
nourished, and the subject of a symmetrical palmar and plantar 
keratosis. The little finger of each hand in the middle of the proximal 
phalanx was closely encircled by a tensely drawn cicatriform linear 
girdle, the constriction of which was rapidly working an amputation 
of the little finger of the left hand, the right being less seriously in- 
volved, and some other fingers incompletely girdled by constrictions 
existing only on the palmar faces. Here the demonstration of the 
cause of the amputation was clearly made, for the callous ring about 
the digits was manifestly in line with the equally dense callosities of 
the palms and soles, which differed from the former chiefly because of 
their occurrence in broad plates rather than in narrow lines. A patient 
presenting the same features was exhibited before the Fourth Inter- 
national Congress of Dermatology, held in Paris in 1900. 

Ainhum is seen chiefly in the natives of Africa, Brazil, West 
Indies, and India, a few cases having been reported from the southern 
states of this country. Herrick 2 recently reported a case in a negro 

1 Transactions Internat. Leprosy Conference, 1897, vol. iii., p. 45. 

2 Phila. Med. Jour., Feb. 5, 1898. 



AINHUM. 537 

who had lived for thirty years in Illinois. It is a disease of adults, 
though it has been reported in a few instances in children. Only 
four times is it recorded as occurring in the white race. The little toe 
is the one usually affected, but the disease may involve the other toes, 
or rarely the fingers. The sensibility of the toe is not lost, but there 
is no pain unless ulceration occur at the bottom of the groove. 

The causes of the disease, which is probably a trophoneurosis, are 
not known, and its pathology is undetermined. There is marked 
atrophy of bone, the amputation occurring commonly through the 
osseous diaphysis instead of the joint. There is marked hypertrophy 
of the epidermis and of the papillary body. The vessels are enlarged 
and thickened, but their calibre is diminished. 

Incision of the constricting ring at an early period is said to relieve 
the disease. In most of the cases amputation is required or is effected 
by the natural progress of the disorder. 



CLASS VI. 
NEW-GROWTHS. 



KELOID. 

(Gr. XV^V, a crab's claw.) 

(Cheloid, Kelis. Fr., Cancroide ; Ger., Knollenkrebs, 

Alibert's Keloid.) 

The term keloid, first given to the disease by Alibert, should be 
restricted to it exclusively. The so-called " keloid " of Addison is 
known to-day more properly as scleroderma. 

Authors have described two varieties of this disease : the " true," 
" spontaneous/' or idiopathic form ; and the " false," " spurious," or 
cicatricial form, which develops in the scar produced by a previous 
traumatism. 

There is no anatomico-pathological separation between the two, and 
it is highly probable that all cases of so-called " spontaneous keloid " 
are instances of development of the growth in regions of pressure, 
contusion, traction, or slight traumatisms that have not been recognized, 
such as the wounds inflicted by mosquitoes. 

Symptoms. — The new-formations of this disease are dense, gener- 
ally elastic nodules imbedded in the corium, or projecting above the 
level of the skin and firmly attached to it. They are usually very 
slow of evolution, and, having once attained full development and 
assumed one of the several shapes which they affect, usually persist 
for a lifetime. These forms are whitish or reddish, globular or semi- 
globular nodules, buttons, or plaques, with roundish or ovoid outline ; 
linear elevated striae, bands, ridges, resembling cords, ribbons, or tapes, 
in irregular outline and disposition ; or combinations of two or more 
of these figures. A common form over the sternum and in other situa- 
tions where the development of the growth in every direction is not 
impeded, is that of a larger central mass with two or more diminishing 
and declining prolongations bearing a remote resemblance to the body 
and claws of a crab. The lesions vary in size from that of a small 
pea to that of a large saucer, the largest including the outlying points 
of the limbs or radiating ridges. Over them the skin is reddish or 
whitish in color, smooth, hairless, and occasionally hypersensitive to 
pressure and heat. Often small blood-vessels traverse its surface. The 
growth at times is also the seat of spontaneous pain. 

The most frequent site of the disease is the anterior surface of the 
chest, but it is observed also upon the face, neck, ears, breast, hands, 

539 



540 



NEW-GROWTHS. 



between the scapulae, and on the extremities (Fig. 63). Keloid is also 
seen upon the penis of the negro. It is far more common in the colored 
than in the white races. Though frequently multiple, there are rarely 
more than a score of these growths visible at one time upon the skin 
of one person. 

The overlying integument at times may wholly be uncolored in 
the white races, and dead whitish in color or even blackish among 
negroes. At other times the surface is not merely pinkish or red- 
dish, but is vividly red in hue. The color is produced by vascular 
connective tissue covering the growth. The subjective sensations 



Fig. 63. 




Keloid. 



aroused are commonly trifling or inappreciable ; at other times the 
growths are the seat of severe pain or of burning. The usual course 
of the disease is toward the production of tumors of a medium size, 
after which few changes are to be recognized. Involution and complete 
disappearance are rare. These results, however, have been secured in a 
few cases. 

Cicatricial Keloid (Scar- keloid, Hypertrophic Scar, 
Hypertrophic Cicatrix) resembles in its features the true keloid 
described above, and differs from it chiefly in the fact that the cicatricial 
form is ordinarily preceded by scar- formation, due either to disease or to 
injury. It thus follows the lesions of zoster, variola, and syphilis, as also 
traumatisms of all sorts, including those made by surgical operations and 



KELOID. 541 

accidents. The tumors, as a rule, spring directly from scar-tissue, and 
after reaching a maximum of development do not surpass the limits of 
the original lesions ; at times, however, the growths slowly develop, as 
in spontaneous keloid, at a distance from the original site of injury or 
disease. Scar-keloid is often found as a firm nodule in the lobe of each 
ear among women, after piercing the ears for the insertion of earrings ; 
it is seen also not rarely as a result of burns, whether produced by 
application of caustic agents or of heat. 

Etiology. — The origin of the disease is exceedingly obscure. Neither 
age, sex, nor previous disorder of the skin seems to have any bearing 
upon its production. It is seen in remarkably vigorous persons (more 
often in the negro race), but also in those who are weakly. The very 
young and very old are more rarely affected. 

Though not yet demonstrated, it is probable that eventually some 
varieties of keloid will be recognized as examples of cutaneous para- 
tuberculosis, the predisposition to the development of the disease in. 
sites of slight traumatism being related to the toxins furnished from a 
distant focus. The race in which its lesions are most often and most 
voluminously displayed is exceedingly prone to tuberculous infection ; 
and the frequent recurrence of the disease after surgical excision and 
the peculiar lupoid aspect of certain keloid lesions are strikingly 
suggestive. 

Pathology. — According to Langerhans, Warren, Kaposi, and others, 
in all cases of true keloid the papillary layer of the corium and the 
interpapillary projections of the rete downward are intact, the new 
formation being strictly limited to the middle and lower portions of the 
corium, in which there are numerous whitish, tendinous fibres of con- 
nective tissue, dispersed for the most part parallel with the surface of 
i the rete. In cicatricial keloid these observers find a partial or complete 
I absence of the papillse and interpapillary processes. Babes, Crocker, 
j and others, on the contrary, find that the papillse and rete may be 
I normal, modified, or absent in either form. Lymph-vessels with pro- 
liferated endothelium, compressed by longitudinal growth of the fibres, 
] pass in both vertical and horizontal planes, for the most part remaining 
i patulous. There are few spindle-cells and nucleated cells. Blood- 
vessels are few in the centre of the tumor, but are numerous at the 
border and in the loose connective tissue surrounding the growth. For 
■ some distance beyond the tumor the adventitia of the vessel shows a 
small-cell-growth which probably develops later into spindle-cells and 
fibres. These, with the included tissue of the corium, form the keloid. 
The sebaceous glands and coil-glands, hair-follicles, and muscles are 
pushed to one side by the new growth and often are atrophied. 

Diagnosis. — The clinical distinction between keloid and cicatricial 
i keloid is of trifling importance. The situations of the lesions of keloid, 
; often over the sternum, the in frequency of multiple tumors, its claw- 
like prolongations, and yellowish-white, reddish, or grayish-white 
color, all point to the nature of the disease. 

Treatment. — Removal of keloid by cauterization and excision is 
not to be practised, as the growth commonly does not fail to reappear. 
Vidal successfully employed multiple linear scarifications. Various 



542 NEW-GROWTHS. 

stimulating applications may also be made with a view to promote 
resorption , such as the spirit of green soap, iodated glycerin, iodine 
in ointment and tincture, and mercurial, salicylated, and lead plasters. 
The employment of these remedies is subject to the danger of stimu- 
lating the growth to greater activity. Where there is pain anodyne 
unguents may be employed topically, such as freshly prepared bella- 
donna plaster, or ointments of belladonna, stramonium, and opium. 
By far the most elegant of these, and the one which also is capable 
of producing an alterative effect, is the oleate of mercury and mor- 
phine. Laurence 1 obtained good results by scarification followed for 
several weeks by moderate pressure, produced with adhesive plaster. 
Ularic and others report successful destruction of keloid with injections 
of 5 to 20 per cent, solutions of creosote in olive oil. Electrolysis has 
given good results in a few cases. 

Internally, quinine, strychnine, arsenic, and potassium iodide have 
been exhibited with varying success. 

Prognosis. — As regards the general condition of the patient the 
prognosis is favorable. Very rarely there is spontaneous resorption of 
the nodule or tumor. Generally the latter may be expected to persist, 
after full evolution is attained, for an indefinite period of time. 

CICATRIX. 

A cicatrix is a new-formation of the skin, replacing connective 
tissue which has been lost by traumatism, by ulceration, or by some 
other pathological process. Most cicatrices, as, for example, those 
following the ulcerations of syphilis, the operations of the surgeon, or 
the dermatitis produced by a severe burn, are reparative in character. 

They vary greatly in shape, size, color, and other features. They 
may be smooth, glossy, shining, scaling, dull whitish in color, or pink- 
ish from vascularization of the surface. They may be linear, fan- 
shaped, circular, corded, ridged, dotted, crateriform, or tumor-like. 
They may be raised above the skin, on a level with it, or depressed 
below it. They may be deeply attached to periosteum or to bone, or 
readily be movable over the panniculus adiposus. They are of deeper 
color when young, and increase in whiteness with age. They are 
unprovided, as a rule, with hairs, or with coil- or sebaceous glands. 

The most insignificant cicatrices are those resulting from clean, 
incised, and punctured wounds and lesions of similar grade. Certain 
peculiarities of cicatrices are seen in special disorders in which they are 
produced. Circular, oval, reniform, horseshoe-shaped, S-shaped, and 
figure-of-eight-shaped scars, thin and flexible, are characteristic of 
syphilis. The cicatrices of variola, zona, and ecthyma are slightly dif- 
ferent each from the other, though all are of small size and depressed. 
Those of tuberculosis and dermatitis calorica of severe grade are exceed- 
ingly irregular and often corded. 

Hypertrophy of cicatrices is the condition already described as 
keloid. Here there is a tumor-like development of the cicatrix, form- 
ing a ridge, button, knob, indurated fold, or puckered and irregularly 

*Brit. Med. Jour., July 16, 1898. 



CICATRIX. 543 

circumscribed, whitish or reddish lesions. In certain individuals these 
lesions may follow almost every traumatism and destructive process to 
which the integument is liable. 

A case of cicatrix undergoing involution has been described by Dyce 
Duckworth, in a man (aged fifty) who suffered from rheumatic fever 
on two occasions, ten years before the date of report. This patient 
had pericarditis, and was blistered over the precordia. Nine months 
afterward lines of cicatricial growth began to form in the scar left by 
the blister, and they rapidly extended ; in two years' time they were 
still enlarging ; in seven years some subsidence was noticed, and, when 
exhibited ten years after their first formation, involution was markedly 
progressing. This case illustrates the frequent origin of scar-tissue, 
its common occurrence over the sternum, and the fact of the subsidence 
of the new-growth in the course of time. 1 

Keloid-like cicatrix of the cheeks following acne is far from uncom- 
mon. Its lesion is usually smoothed down in the process of time, after 
the disappearance of the sebaceous gland-disorder, until the deformity 
is greatly lessened, and often scarcely noticeable. 

Etiology. — The formation of cicatrix is always preceded by destruc- 
tion of at least a portion of the papillary body of the corium. This 
loss of tissue may be due to various causes : trauma, burns, ulcers, 
atrophy caused by pressure of new-growths, etc. Hypertrophied 
cicatrix may result from slight but continued or frequently repeated 
irritation of a healing surface, the repair of which is thus greatly 
delayed, but it occurs chiefly in the form of cicatricial keloid. 

Pathology. — Histologically, scars are made up of connective-tissue 
bundles which interlace in all directions with great irregularity. In 
young scars the fibres are finer and the tissue is vascular, but as the 
scar grows older the fibres usually become coarser and contract and the 
vessels disappear. There is complete absence of hair-follicles, glands, 
and furrows of normal skin. The scar-tissue proper is covered with a 
very thin epidermis, and Heitzmann claims that shallow and irregular 
papillae are always present. Other observers report in scars an entire 
absence of both papilla? and rete-pegs. 

Diagnosis. — The distinction between hypertrophied cicatrix and 
keloid is one chiefly of degree and needless from a practical point of 
view. Following the piercing of the lobule of the ear for the insertion 
of earrings, the lesion is distinguishable by pinching the part between 
the fingers, when a globular-, pea- to cherry-sized mass will be felt 
firmly imbedded in the derma between the reflected folds of the integ- 
ument. Upon the face, after the occurrence of acne, keloid can be 
usually seen as a puckered ridge, often transverse in direction, occu- 
pying the region of the cheek. 

Treatment. — The resources of modern surgery are to be trusted in 
the production of laudable cicatrices when all antiseptic precautions are 
observed. The treatment of pathological conditions likely to be fol- 
lowed by cicatrices is the treatment largely of the special disease in 
which such loss of tissue occurs, e. g., the ulcer left by a degener- 
ating syphilitic gumma of the skin. An irregular or disfiguring cicatrix 

1 Brit. Med. Jour., October 8, 1881, p. 597. 



544 NEW-GROWTHS. 

may be excised if there be sufficient tissue to permit direct union 
of normal tissue on either side. Skin-grafting may be employed after 
excision of larger scars. 

The treatment of hypertrophied cicatrix depends upon its cause. 
If due to individual idiosyncrasy, the treatment is that of keloid. 

FIBROMA. 

(Lat. fibra, a fibre.) 
(FlBKOMA MOLLUSCTTM, MOLLTJSCUM PENDULUM.) 

Symptoms. — Fibroma is a disease characterized usually by the 
occurrence of numerous, roundish, softish, semisolid or solid growths, 
varying in size from that of a small pea to tumors of several pounds 
weight, though more rarely the neoplasm is single. They are often 
called mulluscous fibromata, as the disease was termed at one time 
molluscum fibrosum. When quite small they are seated within or 
beneath the skin, where they can be distinguished as distinctly circum- 
scribed nodules, buttons, or plaques often slightly projecting. When 
more fully developed they become sessile, pedunculated, or largely 
pendulous tumors, hanging from the part to which they are attached so 
as to resemble in shape a cherry, a nipple, a pear, or a sausage. They 
are commonly covered with an integument that is natural in color 
and suppleness, though the latter may be traversed by blood-vessels ; 
sprinkled with comedones or patent orifices of sebaceous gland-ducts ; 
thinned or thickened, or in a state of ulceration ; the last named being 
usually the result of externally operating causes in tumors of large 
size. They are productive of no subjective sensation beyond the more 
or less uncomfortable tension produced by the weight of those attain- 
ing a great size. When multiple they may be seen in various degrees 
of development, covering in hundreds and even thousands the entire 
body, especially the scalp, face, trunk, genitals, and extremities. Upon 
the lids they may interfere with vision by the production of ptosis. 
To the touch they may be felt as softish, somewhat elastic, firm, or 
lobulated masses, though at times nothing but a double fold of skin 
can be perceived, or a cord-like contained body. They are often con- 
genital. When closely set together upon the skin, and of small size 
and pendulous, the features of the disease are characteristic. 

Schwimmer distinguishes between these lesions usually congenital 
(termed by him, soft fibroma), and the dense tumors of similar ana- 
tomical features (termed by him, firm, or hard, fibroma). The latter 
are circumscribed, deeply seated, very slow of development, and apt to 
induce changes in the tissue which surrounds them. They may undergo 
fatty degeneration, or ossification, or calcification. 

The first appearance of the disease may sometimes be recognized as 
a roundish spot over which the skin is uplifted. It is of a light-pink- 
ish color. The tumor is soft and suggests to the touch a thinning of 
the derma beneath. By firm pressure over such lesions when they 
have attained about a centimetre in diameter they may be slowly 
pushed downward into the skin, and the sensation is produced to 



PLATE XV. 




Multiple Fibroma of the Back. 



FIBROMA. 



545 



the touch of a foramen in the derma. Fusion between the new- 
growth and the skin over it is of early occurrence. The spherical or 
oval form of the tumor depends 
upon the direction of the bundles 
of the subcutaneous tissue of the 
part invaded. The tumors may 
undergo involution, but this result 
is more common when the patient 
is under thirty years of age. 
Dermatolysis is produced by great 
activity of the growth of one, or 
fusion of several tumors, by which 
a flap of skin is formed. 

Some of the tumors, usually 
in young subjects, suggest, when 
handled, that they contain boiled 
vermicelli or a number of thread- 
worms. The soft and gelatinous 
quality of the neoplasm in earlier 
life is believed to be proportioned 
to the age of the subject, and a 
rapid development and succu- 
lency of structure are only con- 
ditions of imperfect evolution, and 
are not common in older patients, 
in whom the tumors are firmer 
and grow more slowly. 

When involution occurs after 
maturity of the lesions has been 
attained the softish contents of the 
tumors are adherent to the cutis 
above, and the cutaneous atrophy 
is proportioned to the rapidity of 
development of the growth and the 
firmness of its structure. Then 
ensues a purse-like pedunculation 
of the tumor, produced by en- 
croachment of the skin upon its pedicle, rendering its invagination, suppos- 
ably possible before, afterward difficult or impossible. Gradually there- 
after the neoplasm loses its skin-connection. Eventually in many cases 
only fibrous cords are left, evidently attached to the connective tissue 
beneath, the skin-color paling as the vascular tension correspondingly 
diminishes. Soon the dermal foramen closes, and the involutive process 
is at an end. Then empty and wrinkled pouches or purses of integu- 
ment are left, the further skrinkage of which produces multiple warty 
or nipple-like elevations of tissue (under the microscope recognized as 
fibrous structures with an epithelial envelope), much in color like the 
virgin nipple or the scrotum of a boy. From four months to a year 
are requisite for the mature development of the tumors, and nearly as 
long a period for the completion of the process of involution. The 

35 




Multiple fibromata. (Gboss.) 



546 NEW-GROWTHS. 

dermatolytic flap is permanent. Taylor believes that there is the 
closest possible relation between fibroma and the verrucous growths 
called acrochordon and ecphyma mollusciforme. 

Dermatol ysis (Chalazodermia, Pachydermatocele, Fibroma 
Pendulum, Lax or Relaxed Skin) is a condition which, as appears 
in what precedes, may be produced by fibroma and follow the involu- 
tion of its lesions. In other cases it is apparently spontaneous and 
diffuse, but then it is probably the result of some preceding condition 
that has been unnoticed. The skin of patients thus affected is in a 
condition resembling that of the young of several of the larger among 
the lower animals (pups of large hounds, etc.), where enormous flaps of 
skin may be gathered up between the fingers and extended a foot or 
more from the underlying tissue. On releasing such folds the skin 
retracts to its former position. The skin in these cases is usually 
thickened, but it may be stretched to a considerable tenuity, as in the 
case of a man lately exhibited in America who could cover his face 
with skin drawn up from the surface of the chest. The integument 
may be externally normal to the view or pigmented. It may be the 
seat of molluscous tumors; and either insensitive or normally sensitive, 
or the seat of painful sensations. Usually all the functions of the 
integument are preserved. 

The anomaly is always partial and limited to either the face (the 
lids), the neck, the chest, the belly, or the genital region. The disease 
may be congenital or acquired. 

Dermatolysis, as thus recognized, is to be distinguished from the 
laxity of skin apparent in the senile condition and after distention from 
the presence of tumors, pregnancy, etc. Usually, however, in the last- 
named group of cases it is the subcutaneous tissues which are relaxed 
rather than to any unusual extent the skin itself (e. g., the mammary 
glands of women of advanced years, and the abdominal muscles after 
distention of the belly). 

Etiology. — Fibroma is peculiar to neither sex ; and, though observed 
in adults, is commonly first developed in childhood. It cannot be 
claimed as peculiar to any race, though in America negroes have prob- 
ably furnished the largest field for its observation. Hebra called atten- 
tion to the low standard of physical and mental development of the 
subjects of the disease seen by him, a fact well illustrated in a case 
recently presented, the patient being an exceedingly myopic, poorly 
nourished white male dwarf, whose body was literally covered with 
fibromata from the scalp to the feet. In view of this well-established 
clinical fact, the hereditability of the disease, which is rendered prob- 
able by recorded observations, seems capable of explanation. It has 
been noted in three successive generations and in seven children in one 
family. The cause of the disease is unknown. It is, however, reason- 
able to conclude that it is due to a vice of local development under the 
influence of a constitutional predisposition. 

Pathology. — Simple, soft fibroma of the skin is seen under the 
microscope to be a variety of myxo-fibroma and originates in gelatinous 
connective-tissue elements, which undergo metamorphosis into bundles 



PLATE XVI. 




Fibroma Pendulum. 



FIBROMA. 547 

of fibres, the tumors always exhibiting more of the formed fibrous tissue 
in the outer, and the formative or protoplasmic material in the central 
parts of the mass. In young tumors the fibres are delicate and form a 
loose network containing many spindle-shaped cells. As the growth 
becomes older and harder the fibres become coarser and more closely 
united, forming compact fibrous tissue in which there are very few 
cells. The vascular supply of fibromata is usually slight. The fibrous 
bundles pass downward and unite with those of the derma or sub- 
cutaneous tissue, forming thus a firm attachment for the pedicle of all 
pedunculated tumors. There is some question as to whether these 
growths originate in the deep interspaces of the corium or in the con- 
nective tissue about the hair-follicles or fat-globules. 

A very large number of fibromata are of the so-called " mixed " 
variety. Some spring from the nerve-sheaths, and actually contain 
nerve-filaments (neuro-fibroma) ; others from muscular, vascular, and 
glandular tissues, the compound tumor receiving in this way a part of 
its constituent elements; often warty growths form with participation 
of epithelium in the connective tissue, constituting thus an epithelioma 
(so-called " papilloma"). The large pendulous tumors of nsevus lipom- 
atodes may be examples of mixed fibromata, the surface of which is 
composed of pigmented and hairy skin. 

Diagnosis. — The tumors of molluscum fibrosum are to be distin- 
guished clinically from multiple cutaneous sarcomata by the violaceous 
or reddish color of the latter, the absence of pedunculation, the greater 
tendency to ulceration, and their evidently malignant character. From 
tubercles of lepra they are differentiated by the entire absence of con- 
stitutional impairment and their general development in far greater 
multiplicity. The tumors of molluscum epitheliale differ in their con- 
tents, their superficial location, and in the frequent presence of the 
dark punctum at their summits. 

Neuroma is usually painful ; lipoma less frequently multiple and 
pedunculated, and more suggestive, when handled, of a " pillowy " 
sensation to the touch. Warty growths are readily distinguished by 
their verrucous summits ; and the gummata of syphilis, by the con- 
comitant or prior symptoms of the existence of lues. 

Treatment. — The treatment of large single fibromata is surgical, 
involving the employment of knife, ligature, 6craseur, or galvano- or 
thermo-cauterization. Multiple lesions are often so numerous as to 
forbid such interference. When there is a distinct vice of development 
or inherited tendency to the disease little can be accomplished in the 
way of treatment. 

Prognosis. — Rarely, one or more of these lesions disappear by 
spontaneous involution. More commonly they persist after their evo- 
lution is completed. Marasmus, tuberculosis, and a fatal result may 
occur. One or several of the tumors may become sources of danger 
from the occurrence in them of an active inflammation with resulting 
degeneration and septicemic consequences. The disease, however, does 
not in many cases shorten life. In general the prognosis of multiple 
fibromata may be regarded as unfavorable. 



548 



NEW-GROWTHS. 



NEUROMA. 

(Gr. vevpov, nerve.) 

Symptoms. — But few cases of this rare disease are recorded. ^ The 
description appended is a summary of the symptoms detailed in the 
reports of Duhring, 1 of Rump/ and of Kosinski. 3 

The patients were all men of middle life or advanced years, who 
exhibited upon the shoulders, arms, thighs, or buttocks numerous dis- 
seminated and denned, pinhead- to hazel-nut-sized, spherical or oval 
nodules or tubercles. They were either painful, or painless at the out- 
set and painful later. In Rump's case, which was a sample of the 
false neuroma of Virchow (fibroid tumor of the nerve), there was no 
pain throughout the course of the disease. 

Fig. 65. 




Neuroma of the skin: external appearance. (Duhring.) 

The nodules were not arranged along the tracts of nerves ; were 
immovable, dense, and elastic ; were fixed in the corium and extended 
below it. They were purplish or pinkish in color ; and the skin 
between them was unaltered, or like that enveloping the lesions, dry, 
uneven, and desquamative. The tubercles were both tender and pain- 
ful, the pain being excruciating, paroxysmal, usually lasting in Duhr- 
ing' s patient for an hour, and radiating. It was aggravated by tem- 
perature-changes, mental emotion, and movement. 

1 " Case of Painful Neuroma of the Skin," Amer. Jour: Med. Sci., October, 1873; 
also supplement to the same, with cuts, October, 1881. 

2 Arch. f. path. Anat. u. Phvs., Bd. lxxx., Heft 1. 

3 Centralbl. f. Chir., 18'74, No. 16. 



NEUROMA. 



549 



Histologically these tumors are composed of a mixture of fine con- 
nective tissue with medullated and non-medullated nerve-fibres ; and 
should properly be called neuro-fibromata. Sections of the growth in 
Duhring's case showed anatomically a connective-tissue stroma, inter- 
woven with fibres for the most part lying parallel with one another, 
each fibre composed of a finely granular central substance surrounded 
by a sheath containing numerous, elongated, oval, somewhat granular 
nuclei. There were also yellow elastic tissue, blood-vessels with thick- 
ened and nucleated walls, and about the latter lymphoid, cell-like 
bodies. There was entire absence of unstriated muscular and fibrillar 




Microscopic structure of neuroma. (Duhring.) 



connective tissue. The specimen represented the true amyelinic neuro- 
mata of Virchow. In Kosinski's case non-medullated nerve-fibres and 
connective tissue were also discovered. In both cases exsection of a 
portion of nerve (brachial plexus, of the one ; and small sciatic, of the 
other) was followed by considerable diminution of pain and almost 
entire disappearance of the growths. In Rump's case, which, as stated 
above, represented the fibromated and so-called fibro-nucleated tumors 
of Yirchow, the nodules were strung upon the same nerve, "like beads 
upon a rosary," and were similarly displayed upon its branches. 
Spinal, cerebral, and sympathetic fibres were all involved. 

Duhring, in commenting upon these rare cases, calls attention to the 
distinction between purely cutaneous lesions and the generally solitary, 
movable, and " painful subcutaneous tubercle. " 



550 NEW-GROWTHS. 

Knauss l reports a case in a girl of eleven years. There were over 
sixty tumors varying in size from a cherry to a hen's egg. They were 
situated beneath the skin, were firm and elastic, and never painful. 
Histological examination showed them to be composed of medullated 
and non-medullated nerve-fibres, and numerous ganglionic nerve-cells. 

XANTHOMA. 

(Gr. ^avQoq, yellow.) 

(Xanthelasma, Yitiligoidea. Fr., Plaques jaunatres des 

Paupieres.) 

This affection w T as described by Payer 2 under the title Plaques 
jaunatres des Paupieres; by Addison and Gull (1851) as Vitiligoidea ; 
by Erasmus Wilson as Xanthelasma; and by W. F. Smith (1869) as 
Xanthoma, the name now generally accepted by writers. 

Symptoms. — -Two forms of the disease are commonly recognized : 
Xanthoma planum and Xanthoma multiplex. 

Xanthoma Planum. — The flat or plane forms of the disease ap- 
pear as pinhead- to finger-nail-sized plaques, either quite flat or with 
slightly elevated borders, and covered with an apparently normal 
integument. In color, which may be rendered more distinct by 
stretching the skin, they vary from light- or chrome-yellow to a 
" coffee-and-milk " shade ; and in shape they may be punctiform, 
spherical, oval, elongated, or of irregular outline. They are distinctly 
circumscribed, and when gathered between the thumb and finger are 
soft and smooth, and do not produce a sensation of the presence of a 
foreign material. The plaques, examined closely, are seen to be made 
up of an aggregation of millet-seed-sized, yellowish nodules, each pro- 
vided commonly with a somewhat reddish central point. The plaques 
are most often seen upon the eyelids (Xanthoma Palpebrarum), near 
the inner canthus, where they may be symmetrically disposed about the 
two orbits, first appearing on one side ; but they may invade also the 
periorbicular region, as also, rarely, the cheeks, the nose, the ears, and 
the nucha. They are rarely productive of subjective sensation, being 
occasionally the seat of slight pruritus. This is the commoner form of 
the disease. 

Xanthoma Multiplex (Xanthoma Papulatum, Tubercula- 
tum, Tuberosum) is the form in which the lesions, usually first mani- 
fested in the sites of election and in their simplest development,- pro- 
ceed to a gradual invasion of the trunk and extremities. The regions 
of greatest pressure, outside of the lids and cheeks, seem sites of pref- 
erence, as, for example, over the elbows, knees, palms, and buttocks. 
Occasionally the mucous surfaces of the mouth, of the respiratory and 
gastro-intestinal tracts are involved, as also the surfaces of the peri- 
toneum, endocardium, and larger arteries. The genital region, pal- 
ate, oesophagus, spleen, trachea, and cornea have all been recognized 
as seats of the disease. Papular and tubercular lesions may coexist 

1 Virchow's Arch., 1898, Bd. cliii., S. 29. 

2 Traite* prat, des Maladies de la Pean. Paris, 1836. 



PLATE XVII. 




Xanthoma of the Hands, Elbows, and Knees. 



(From a Photograph of one of the author's patients.) 



PLATE XVIII. 








Xanthoma Tuberosum of the Hands. 

(From a painting.) 



XANTHOMA. 551 

with the plane lesions described above, and scarcely differ from the 
latter save in a greater development. The lesions are whitish or yel- 
lowish papules, plaques, and tubercles, circumscribed in contour, 
millet-seed- to nut-sized, and at times much larger, covered with an 
unaltered epidermis, and determinable by palpation as having greater 
consistence than the flat macules. They are less frequently seen upon 
the lids, but occur upon the scalp, cheeks, palmar and plantar surfaces, 
the genital region, and about the joints of the digits. 

In rare cases the tubercles may coalesce to form sessile or pedun- 
culated, nut- to hen's-egg-sized tumors which are firmer as a rule than 
the smaller lesions (Carj^and Chambard 2 ). 

The conglomerate forms upon the skin constitute large plaques 
resembling tumors, compounded of lesions of xanthoma tuberosum. 
They are distinctly circumscribed, deeply imbedded in the coriuni, 
elevated to the extent of one-fourth of an inch above the general level 
of the integument, and irregularly furrowed or lobulated superficially. 
An illustration from a photograph of xanthoma occurring in full de- 
velopment and in rare situations is presented in the plate appended. 

Other cases display unusual features of this disease. In one there 
are flattened ribbons, exhibiting xanthomatous changes in both palms, 
stretching at right-angles to the long axis of the hand ; in a second 
and somewhat rare form of the disease isolated xanthomatous papules 
are attached somewhat regularly to the edges of the lids of both eyes, 
the upper and lower equally, while large pinhead-sized and equally 
isolated yellowish masses are visible below the orbits on each cheek. 

In certain cases the disease is accompanied by a generalized colora- 
tion of the skin in a yellowish shade, which has been variously inter- 
preted as a xanthomatous dyschromia and as a true icterus. The 
former is the more probable explanation of the fact, as in such cases 
the urine and viscera have been found normal. A woman presenting 
one of the extreme phases of this icteroid xanthomatous condition of 
the skin was shown at the International Congress of Dermatology in 
London in 1896. 

Korach 3 has described the case of a woman twenty-five years old, 
suffering from chronic icterus produced by closure of the ductus 
choledochus. Beside the typical patches of xanthoma on the lids, 
the skin-surface was generally and similarly' affected. Thus the 
extensor faces of the extremities, the palms of the hands, nates, and 
other parts w T ere extensively covered with sago-grain- to pepper-corn- 
sized papules and tubercles of xanthoma, both flat and elevated. 

Occasionally the tubercles exhibit a fine vascularization ; and when 
there is a coincident jaundice the skin between isolated lesions is also 
tinted with the color of the xanthoma nodules. The jaundice, so- 
called, is rather common in the multiplex forms ; and even when not 
readily recognized the skin, at first sight of normal tint, is seen to be 
somewhat deeply colored in a shade of reddish yellow. As a rule, 
there are scarcely distinguishable subjective sensations, patients coni- 

1 Annal. de Derm, et de Syph., 1880, p. 7o. 

2 Arch, de Phvs. norm, et path., Sept. and Dec, 1879. 

3 Deutsch. med. Woch., 1881, No. 20. 



552 NEW-GROWTHS. 

monly applying for relief of the resulting facial disfigurement. Occa- 
sionally burning and pricking, and rarely even painful sensations are 
produced. The patient whose lesions were selected for illustration of 
this chapter subsequently had the tumors removed from his limbs in 
order to relieve himself of discomfort in his work. 

The course of most cases is toward a maximum of development, 
after which the process ceases. In a few instances, usually not palpe- 
bral, complete involution has spontaneously occurred. The variations 
noted in the color of the plane and elevated forms of xanthoma are 
from a light-yellow to a deep-brownish and even blackish hue. Cases 
occurring in children and infants seem to exhibit nearly the same fea- 
tures as those seen in adults. 

Etiology. — The causes of the disease are obscure. In a few cases 
the lesions are first observed in early childhood, though they are 
encountered chiefly in middle and later life. Women are rather more 
often affected than men. 

The belief is growing that xanthoma is due to embryonic and local 
causes. Many instances are on record in which several members of a 
family were affected. Torok and T. C. Fox have each reported families 
in which members of three generations presented the disease. The 
mother of the patient exhibiting multiple lesions upon the elbows and 
knees, whose case was selected for illustration of these pages, presented 
plane lesions of xanthoma near the inner canthi of the eyes. The 
studies of Torok 1 in this direction are instructive. The association of 
xanthoma with disease of the liver, rheumatism, gout, ovarian disease, 
migraine, syphilis, carcinoma, hydatids, and other disorders cannot be 
denied for certain cases, but in the majority no such association can be 
recognized. Multiple plane lesions of the lid in a middle-aged woman 
have succeeded a dermatitis of that region, induced by accidental con- 
tact with a corrosive solution of mercury. 

Pathology. — The anatomy of xanthoma has been investigated spe- 
cially by Chambard, Balzer, Touton, 2 Torok, and others. The process 
seems to be a connective-tissue new-growth, containing cells infiltrated 
with fat-granules. Aside from the new-formed connective tissue and 
endothelial cells there are seen between the interlacing fibres the char- 
acteristic " xanthoma-bodies." These are cells varying greatly in size, 
having a distinct membrane, granular or fibrillated protoplasm, and 
large round or oval vesicular nuclei, which vary in number from one to 
a dozen or more. 

These " xanthoma-cells " are grouped especially about and along the 
vessels, and form globular masses in the deeper parts of the corium, 
though they may extend almost to the rete. They are more or less 
infiltrated with fat-granules, and correspond closely in structure to the 
developing fat-cells of normal connective tissue, but, as Torok has 
shown, they never go on to the formation of a fully developed cell 
containing one large drop of fat, and Unna finds they do not respond 
to staining and other tests as do the fat-containing cells found in other 

1 Annal. de Derm, et de Syph., Nov. and Dec, 1893. 

2 Vierteljahr. f. Derm. u. Syph., 1885, Heft 1, S. 3, with reference to previous re- 
ports. 



XANTHOMA. 553 

tissues. There is seen also in the growth a transitional series of 
bodies between the connective-tissue corpuscles and the characteristic 
" xanthoma-cells." 

The epidermis is usually unchanged, though it, together with the 
papillary layer, may be slightly thinned, and there is frequently a 
deposit of a yellowish-brown pigment in the deeper layers of the rete. 
The growth is almost wholly confined to the deeper parts of the corium, 
though occasionally portions extend to the subcutaneous tissue and may 
surround the coil-glands and hair-follicles. The sebaceous glands may 
be few, but are unchanged and are not, as was formerly supposed, con- 
cerned in the process. There is often a deposit of pigment in the corium, 
both free and in the cells, but the characteristic color of xanthoma is 
undoubtedly due to the fat-granules. 

The icterus and hypertrophy of the liver which sometimes complicate 
xanthoma are probably secondary and caused by the presence of the 
growth in the liver or in the biliary passages. 

Pollitzer 1 has made a study of xanthoma palpebrarum, and states 
that this form of the disease is due to a slow fatty degeneration of 
the fibres of the orbicularis muscle analogous to the more rapid 
degeneration of muscles which sometimes follows acute infectious dis- 
eases. He finds the xanthoma-bodies to be fragments of degenerated 
muscle-fibres, and believes that this form of the disease has no connection 
whatever with the generalized forms. 

Chambard, Morris, Crocker, and a few others believe the primary 
process is an inflammation which is followed by a fatty degeneration of 
the cells. 2 Balzer's conclusions as to the parasitic nature of the disease 
have not been verified by more recent investigators. 

Diagnosis. — Milia occasionally occur in groups in the form of oval 
plaques upon the lids, but are distinguishable from xanthoma by the 
possibility of expressing their contents. 

The diagnosis from all other lesions is readily made when consider- 
ation is had of the peculiar yellowish or saffron-like hue of xanthoma, 
and the common situation, form, and general characteristics of its plane 
or nodular lesions. 

Pollitzer has reported a case of multiple dermoid cysts in which were 
present the clinical appearances of xanthoma. A similar case is now 
under our observation. 

Treatment. — Erasion and excision are the usual methods of remov- 
ing xanthomata. Care should be taken in such operations to avoid a 
consequent ectropion Avhen the operation is performed upon the skin 
of the eyelids. The Paquelin knife is objectionable on account of the 
radiation of heat to the globe of the eye. With the tumor slipped 
through an aperture in a thin sheet of asbestos paper, such as is now 
found in the market, this danger may be obviated. 

The modern method, however, of treatment by electrolysis is prefer- 
able to others. Caustics also have been successfully employed. Besnier 
employs phosphorus internally, followed by turpentine, by which the 

1 Jour. Cutan. and Gen.-Urin. Dis., 1897, p. 367. 

2 A discussion of this question and a resume of literature are found in the Brit. 
Jour, of Derm., August, 1892. 



554 NEW-GMOWTBS. 

course of the disease is said to have been relieved. Wilson, with the 
same end in view, employed nitro-muriatic acid, arsenic, bitters, and 
blue pill. McGuire reports the removal of xanthoma by applications 
of monochloracetic acid. 

Prognosis. — The lesions, when not removed, are liable to persist 
through life. Spontaneous involution is said to occur very rarely. 
French authors who have given considerable attention to this subject 
are disposed to believe that some cases of xanthoma tuberosum, with 
permanent xanthochromia and involvement of the inner coats of the 
larger vessels, may prove serious. 

XANTHOMA DIABETICORUM. 

(Glycosueic Xanthoma.) 

This rare disorder has been well illustrated by three excellent por- 
traits showing the features of the malady in a case reported by Robin- 
son. 1 Instances of the disease have been also recorded since the cases 
of Addison and Gull (1851), by Hillairet, Morris (who was the first to 
claim for it an independent position in the list of cutaneous affections), 
ourselves, 2 and many others. 

Symptoms. — The lesions are usually multiple and numerous, dis- 
crete or confluent, and not rarely grouped, pinhead- to pea-sized, firm, 
well-defined, conical or acuminate papules. At the apex may be recog- 
nized a yellowish centre with reddish areola, which may be made to 
disappear temporarily under pressure. The appearance when viewed 
at some distance is suggestive of a pustule. Subjective sensations of 
itching, pricking, etc., may be produced. The lesions are visible over 
the buttocks, loins, elbows, knees, and extensor faces of the limbs in 
general, the face (broAvs, nose), the scalp, about the angles and over the 
mucous surface of the mouth, and the palms and soles. But one case 
has been reported as occurring on the eyelids. The eruptive lesions 
are likely to be of sudden occurrence. After remaining upon the sur- 
face for a few months or years they may wholly disappear without 
leaving a trace of their existence, or the eruptive elements may in part 
only disappear. 

Etiology. — In seventeen out of twenty-one cases reported glycosuria 
has been recognized ; and Johnston calls attention to the fact that in 
nearly every case the patient has been described as stout, florid, or 
obese. The majority of the patients have been male subjects, and 
usually in a condition of fair nutrition ; often they have been consumers 
of beer in large quantities. 

Pathology. — Histologically the disease does not differ essentially 
from the ordinary form of xanthoma, except that the inflammatory 
changes are more marked, there is less connective-tissue formation, and 
there are fewer of the xanthoma-cells than in the common variety. 
The lesions, moreover, are usually found near the coil-glands and fol- 
licles. Torok, Johnston, and others believe the disease to be an exuda- 

1 Internat. Atlas of Kare Skin-diseases, 1890, iv., ii. 

2 Paintings in oil showing the lesions in two patients were exhibited to the Amer. 
Derm. Assoc, in New York, 1898. 



PLATE XIX. 



I 



Xanthoma Diabeticorum. 

(From a painting.) 



COLLOID METAMORPHOSIS OF THE SKIN. 555 

tive dermatitis terminating in a granulo-fatty degeneration which is 
quite distinct from the heterotopic, arrested development of fat seen in 
ordinary xanthoma. 

Diagnosis. — Those who would separate this form of xanthoma from 
all others base the difference between them upon the following points : 
in xanthoma of glycosuria the sudden evolution and involution of the 
cutaneous lesions ; the firmness and solidity of the latter as distinguished 
from the softness of the ordinary forms ; and the inflammatory character 
of the glycosuric as distinguished from the hypertrophic changes in the 
other variety. In xanthoma diabeticorum the yellowish apex is not at 
first apparent, nor in all the lesions, and, when it exists, is due to epi- 
dermal changes and not to those occurring in the corium as in xanthoma. 
Other characteristic features of the xanthoma of diabetic subjects are 
the absence of striae and patches, the absence of jaundice and of eyelid- 
lesions, the presence of marked subjective sensations, the grouping of 
the lesions about the hair-follicles (well marked in Robinson's case), and 
the absence of diabetes mellitus in most of the palpebral cases on record. 
This side of the question is presented by Johnston in reporting a case 
and in giving a summary of the twenty other cases so far recorded. 1 

On the other hand, it is urged by Besnier and Doyon that the gly- 
cosuria is simply an irritating cause which explains the differing symp- 
toms of xanthoma in the two classes of patients. Surveying the litera- 
ture of xanthoma, they find patients without diabetic symptoms suffering 
from atrocious pruritus and most of the special features claimed as 
peculiar to diabetic xanthoma of glycosuria. A woman, however, in 
middle life, recognized as the subject of diabetes mellitus (not insipidus), 
examined with special care, exhibited merely the common form of sym- 
metrical and plane eyelid-lesions. It is difficult to determine what are 
the relations, if any, between these two forms of xanthoma. 

The Treatment of the disease, medicinal and dietetic, is largely that 
of glycosuria. Robinson's patient recovered after the use of small 
doses of Fowler's solution. Local treatment may be employed as in- 
dicated in any case. 

The Prognosis is favorable, all cases eventually recovering. 

COLLOID METAMORPHOSIS OF THE SKIN. 

(Colloid Milium [Wagner], Hyaloma. Fi\, Colloidome 
Miliaire [Besnier] ; Ger., Hyalom dee Haut.) 

Relatively few cases of this rare disorder have been reported. The 
lesions occur chiefly on the upper two-thirds of the face, especially on 
the forehead and about the orbits. They consist of pinhead- to millet- 
seed- or even split-pea-sized, sharply circumscribed, iregularly rounded, 
flat papules, lemon yellow in color, having a peculiar glistening, trans- 
lucent appearance suggestive of vesicles. They project but slightly 
from the skin, and on puncture give exit to a soft gelatinous mass, 
at times accompanied by a droplet of blood. Some of them may be 
surrounded by very slight telangiectases. They develop slowly, often 

1 Jour. Cutan. and Gen.-Urin. Dis., October, 1S95; and Ibid., September, 1900. 



556 NEW-GROWTHS. 

in groups, the individual papules remaining distinct even when two 
or more unite. Frequently a papule becomes depressed in the centre ; 
or becomes inflamed and covered with a crust which falls and leaves a 
shallow depression but not a true scar. 

Etiology. — The cause of the disease is not known ; it occurs alike 
in men and women, usually after the forty-fifth year of age. A male 
patient presented at our clinic was twenty-five years of age only. In 
most of the cases reported the individuals lived an outdoor life and 
were much exposed to the elements. 

Pathology. — This has been studied by Balzar, Besnier, Reboul, and 
others. Wagner's belief that the process begins in the sebaceous 
glands is now practically discarded. Colloid degeneration is found to 
affect the connective-tissue and elastic fibres of the derma, which may 
become involved over considerable areas. The changes are especially 
noticeable about the vessels and nerves and about the sebaceous and 
coil-glands. The glands themselves, and all the epithelial structures, 
except the endothelia of the vessels, usually escape. In sections exam- 
ined by us removed from a clinical patient a few rete-cells and a few 
cells of the coil-gland ducts were transformed into or infiltrated with 
colloid substance. This disease is not identical with multiple benign 
cystic epithelioma (hidradenoma), in which the epithelial cells play an 
important part. 

Diagnosis. — The disease is apt to be confounded with xanthoma, 
hydrocystoma, adenoma sabaceum, and multiple benign cystic epithe- 
lioma (hidradenoma). From the last-named disease the diagnosis is 
often very difficult or even impossible without the aid of histological 
examination. 

Treatment. — The nodules may be removed with a sharp curette or 
by electrolysis. 

ADENOMA OF THE SEBACEOUS GLANDS. 

(Adenoma Sebaceum. Fr., Adenomes S^baces [Balzer and 
Menetrier], Adenomes Sebaces Cancroidaux, Acne Can- 

CROIDALE.) 

The several forms of adenoma of the sebaceous glands may be 
assigned to two categories, the benign and the malignant. 

Acquired Benign Growths are pinhead- to pea-sized, sessile, 
spheroidal, oval or acuminate bodies, occasionally presenting points of 
whitish appearance suggestive of milium. They are situated chiefly 
over the face (forehead, furrows beside the nose). They are always 
covered with an unchanged epithelium and in color present the hue of 
the normal skin. 

Congenital Benign Growths are represented by the verrucous 
and vascular nsevi of Pringle and Darier. They increase slowly after 
birth and attain a notable development at about the period of puberty. 
They also are found about the regions of the face named above, includ- 
ing the chin and the mouth. The lesions are pinhead- to bean-sized, 
and differ from those above described chiefly in the color they present, 
which varies from a yellowish white to a deep brownish red ; often 



ADENOMA OF THE SEBACEOUS GLANDS. 557 

the surface is vascularized by the presence of minute capillaries. 
They are sometimes discrete, often confluent, and may be commingled 
with comedones, acne-pustules, pigmented patches, and the lesions of 
facial seborrhoea. In the majority of cases other defects of the skin, 
such as warts, nsevi, small papillomata, and pigment-spots, are present, 
while many of the patients reported have been mentally deficient or 
epileptic. 

The two forms named above are benign tabulated tumors of the 
type of sebaceous adenoma ; the last-named group being distinguished 
by delicate telangiectases over the surface and a verrucous structure. 

Malignant forms of Sebaceous Adenoma occur when the skin 
is in the senile state. They begin with the symptoms of an irritable 
acne or seborrhoea, greasy crusts being displayed here and there, par- 
ticularly over the surface of the face ; or comedones of unusual 
type ; or papulo-pustules that do not pursue the course of those seen 
in earlier years. Ulceration attacks the lesion which at first seemed 
benign, and the issue is the development of an epithelioma. 

Etiology. — The cause of these growths is not known. The majority 
of them are congenital, and those also which develop later in life may 
be congenital in origin. Most of the cases reported have been in the 
poor and in those of defective mental development, but cases are also 
seen in the well-to-do and intelligent. 

Pathology. — The histology of these bodies has been studied by 
Pringle, Darier, Balzer, Crocker, Pollitzer, and others. There is 
hyperplasia of the sebaceous glands, which are numerous and large. 
Beyond this observers do not agree, and further study of the subject 
is necessary. Pringle described an interpapillary hypertrophy ; Balzer 
found small cysts in both sebaceous and sweat-glands ; Crocker reported 
an increased development of the coil-glands and hair-follicles, in addition 
to hyperplasia of the sebaceous glands. 

Diagnosis. — The history of the disease, which begins in early life 
and develops gradually ; the persistency and permanency of the indi- 
vidual lesions situated chiefly on the middle of the face and specially 
in the naso-labial folds ; the frequent occurrence of telangiectases with 
the papules above described ; and the absence of suppuration or ulcer- 
ation will usually suffice for a diagnosis. In colloid milium the lesions 
are usually few in number, are situated chiefly on the frontal and 
orbital regions, have a peculiar yellowish, translucent appearance, and 
are not so much modified by telangiectases. In multiple benign cystic 
epithelioma the lesions occur on the forehead and also on the trunk. 
Both of the two last-named diseases, however, may so closely resemble 
adenoma sebaceum as to render the differential diagnosis impossible 
without the aid of histological examination. 

Treatment. — Neither internal remedies nor external applications 
have any influence upon the lesions. The treatment is, therefore, 
surgical and calls for the employment of the knife, the curette, or scar- 

Iification, depending upon the size, number, and location of the lesions. 
In several cases the latter have been removed successfully by means 
of electrolysis. 



558 NEW-GROWTHS. 

ADENOMA OF THE COIL-GLANDS. 

Although the majority of cases formerly described as adenoma of 
the coil-glands are now classed with multiple benign cystic epithelioma, 
a few well-authenticated examples of the disorder are reported. 1 
Perry 2 describes a case, illustrated by a chromolithograph, of a 
woman upon whose face and trunk millet-seed- to small pea-sized 
nodules were visible, lasting for nearly twenty years. Upon puncture 
a clear fluid could be expressed from each. On section the coils of 
the sweat-glands were found enormously increased in size, and there 
was pigmentation of the gland-cells. 

The Diagnosis of this rare disorder can be made only with the aid 
of the microscope. 

The Treatment is surgical, by means of the knife, curette, cautery, 
or electrolysis. 

MULTIPLE BENIGN CYSTIC EPITHELIOMA. 

(Adenoma of the Sweat-glands [Perry], Epithelioma Ade- 
noides Cysticum [Brooke]. Fr., Cellulome £pitheliale 
Eruptif Kystique [Quinquaud], Cystadjenomes Epithe- 
lieux Benins [Besnier], Hydradenomes Eruptifs [Jacquet 
and Darier], Syringo-cystadenome [ToroK] ; Ger., Gutar- 
tiges Epithelioma, Verbunden mit Kolloider Degen- 
eration [Phillipson].) 

The name selected as the title of this chapter is that given to the 
disease by Fordyce, whose presentation of the subject forms 3 the basis 
of the following description. 

The disease is most common on the face, neck, and upper extremi- 
ties, but may develop on any part of the body. It is characterized by 
the appearance of small, pearly, pale, yellow or pinkish-colored tumors 
varying in size from a small pin's head to that of a pea. Larger 
lesions are exceptional. The tumors are firmly imbedded in the skin 
and also project above the surface ; they are round or oval, solid and 
painless to the touch, the larger ones being tense, lucent, and freely 
movable. Some of the tumors are translucent, suggesting vesicles ; 
others resemble milia and may be the seat of fine telangiectases ; in 
others there may be a central depression which in some of the larger 
lesions of White's case produced an appearance closely resembling 
Hutchinson's crateriform epitheliomata. The lesions are discrete, and 
are not grouped or arranged in any characteristic manner. 

In most cases the tumors are first noted at or before the age of 
puberty ; they enlarge slowly, rarely exceeding the size of a pea, and 
do not ulcerate or undergo spontaneous involution. White, 4 however, 
reports a case in a woman of forty-five on whose face were small typ- 
ical lesions of this disease, and also others in varying stages of devel- 

1 Fordyce gives a summary of the subject in Morrow's System, vol. ih\, p. 618. 

2 Internat. Atlas of Rare Skin-diseases, 1 890-91. 

3 Morrow's System, vol. iii., p. 620. 

* Jour. Cutan. and Gen-Urin. Dis., 1894, p. 477. 



MULTIPLE BENIGN CYSTIC EPITHELIOMA. 559 

opment up to true epithelioma of rodent ulcer type. The diagnosis 
was confirmed by the histological examination of a number of the 
tumors of varying sizes. 

The cause of the disease is not known. In Brooke's and White's 
cases a distinctly hereditary history was obtained. 

Pathology. — The views of different observers regarding the path- 
ology of this disease are largely indicated in the names given to it by 
each. Fordyce reports that microscopical examination shows the 
tumors to be " made up of irregularly rounded, oval, and elongated 
masses and tracts of epithelial cells corresponding to those in the lower- 
most layer of the epidermis and the external root-sheath of the hair- 
follicle. The epithelial masses may be distinct, or made up of inter- 
communicating bands and tracts, in some places resembling coil-ducts. 
Cell-' nests ' are met with as in malignant epithelioma, enclosing horny, 
granular, and colloid tissue. Colloid degeneration of individual cells is 
also encountered in the cell-masses. The connective tissue about the 
cell-collections is somewhat condensed, but is not the seat of any in- 
flammatory process." It is probable that these epithelial growths 
originate in a downward growth and proliferation of the epidermis and 
external root-sheaths of the hair-follicle, and not from the coil-glands, 
as. was supposed by some observers. 

Two cases only of those so far reported have shown any tendency 
to become malignant. It is possible that in the two cases these 
changes were accidents or coincidents such as occasionally occur in 
connection with verruca and other benign growths, but the histological 
structure of the small tumors closely resembles that of true epithe- 
lioma, and, as White suggests, it is quite possible that they would all 

; in course of time show a malignant tendency, since most of the cases 

'' observed so far have been in young subjects. 

Treatment. — The treatment is wholly surgical, with knife or curette. 

| Many of the tumors are readily expressed with slight pressure, after 
the skin over them has been incised. Electrolysis is suitable for the 
smaller growths. 

Lymphangioma Tubekosum Multiplex. — These rare growths 
< supposedly of lymphatic vessels in the skin have been noted by Hebra 
and Kaposi, Pospelow, 1 Van Harlingen, 2 and other writers. The 
lesions in these several cases were practically identical, from a clinical 
; standpoint, with those of multiple benign cystic epithelioma described 
'above. By many observers the tw r o diseases are thought to be the 
same clinically and pathologically, but Kaposi and others maintain 
that they are distinct in origin and in structure, stating that sections 
show under the microscope rounded or oval spaces, recognizable as dis- 
tended lymphatic vessels by the characteristic endothelium with which 
they were lined. Kaposi distinguishes these tubercles from all subcu- 
taneous cavernous tumors constituted of new-formed dilated lymphatic 
vessels reaching toward the skin, by the limitation in the former of 
the neoplastic growth to the superior parts of the corium. 

1 Y^ierteljahr. f. Derm. u. Svph., 1879, Heft 4. 

2 Phila. Med. Times, September 24, 1881. 



560 NEW-GROWTHS. 

LEUCOKERATOSIS BUCCALIS. 

(Leucoplasia, Leucoma, Psoeiasis Lingua, Smokees' Patches 
of the Mouth, Buccal Psoeiasis, Ichthyosis Linguae, 
Tylosis Linguae, Leucoplakia Buccalis. Ft., Leucoplasie, 
Plaques Blanches de la Bouche.) 

In the year 1868 Bazin described with tolerable accuracy the several 
conditions indicated by the names given above ; and since that date the 
subject has been enriched by a literature contributed by Debove, Kaposi, 
Sigmund, Plumbe, Mauriac, Schwimmer, Ingals, and others. The title 
of these paragraphs is that given by Besnier and Doyon as the least 
misleading and the most descriptive. 

The disease is manifested chiefly in the mouth, by the occurrence on 
the inner faces of the lips and cheeks, and on the dorsum and edges of 
the tongue, of sharply outlined, dull-whitish, slate-colored, or silver- 
whitish points, disks, streaks, bands, ribbons, or patches of an irregular 
shape, either flattened or slightly elevated above the general level of 
the mucous surface. The disease may occur in isolated points or in 
pinhead-sized nodules, discrete or confluent, and in cases grouped, the 
grouping being often in linear arrangements, following the lines indicated 
by the streaks or the striae of similar composition. 

The sites of election of these lesions are : the inner face of the cheek 
in a line following that traced by the conjunction of the teeth of the 
upper and lower jaw when approximated ; the gums above the upper 
canine teeth and lateral incisors; the sulcus beside the upper and lower 
gums in the roof and floor of the mouth ; the dorsum and edges of the 
tongue, where the arrangement is usually in lines along the longitudinal 
axis ; and more rarely other parts such as the vaginal and other mucous 
membranes which have been involved. 

When closely examined these lesions are found to be made up of a 
hyperkeratinized epithelium, being covered by an adherent and more 
or less dense pellicle, removable only by artificial measures and closely 
applied to the inferior stratum of the mucosa. The lesions are rough 
to the touch, both to the finger of the physician and to the tongue of 
the subjects of the disease, but are, as a rule, not painful, though at 
times annoying by producing a certain degree of stiffness and immobility 
of the parts affected. At times the membrane in the vicinity is reddened 
and tender. 

These lesions are extremely chronic of evolution, requiring months 
and often years for their full development, and resisting in a remarkable 
way the action of topical medicaments. They may be removed without 
recurrence ; or may recur after complete and radical ablation. If 
unmolested and not undergoing resolution (a termination somewhat 
doubtful of occurrence), they usually, by reason of increased density, 
crack or fissure at one or another point, the fissure extending to the 
derma and arousing a local inflammatory process with the production 
of pain and distress. The surface is then prone to exfoliate and ulcer- 
ate, and epithelioma of the mouth may result. 

The proportion of .the benign cases to those which result in epithelioma 



LEUCOKEBATOSIS BVCCALIS. 561 

is not determined. Every leucokeratosis, however, may prove the initial 
stage of an epithelioma, and the treatment of the former is, therefore, a 
matter of no little consequence. 

The Etiology of these cases is suggested by some of the names given 
above. The disorder occurs almost exclusively in the mouth of men, 
and usually after middle life. Unquestionably, the irritation produced 
by tobacco, whether used in smoking or chewing, and the influence of 
carious teeth or those with sharp edges after fracture irritating the edge 
of the tongue, are all important. The resemblance of these lesions to 
the mucous patches of syphilis is obvious ; and it is believed that 
syphilis, when not actively efficient in the production of leucokeratosis 
buccalis, may be one of its indirect causes. It is, however, important 
to note that all the symptoms here described occur in persons who have 
never suffered from syphilis ; and such symptoms are in the latter class 
fully as intractable as in others. 

Pathology. — It is not definitely known if the primary change is a 
pure hyperkeratinization of the epithelium or an inflammatory process 
of the papillary layer. The horny layer is hypertrophied, the cells 
retaining their nuclei. In the derma there is always more or less in- 
flammatory infiltration, and often the papillae are partially obliterated. 
Fordyce states that overgrowth and proliferation of the interpapillary 
processes are exceptional. Leloir insists that the epitheliomatous process 
always begins not at the level of the hyperkeratosis of the mucous 
membrane, but below the fissure or other lesion induced by the indura- 
tion of the plaque or streak, indicating, in other words, that the epithe- 
liomatous change is rather an accident than an essential part of the 
process. 

The Diagnosis is chiefly from syphilitic lesions of the mouth, which 
should be recognized, as a rule, by their softness and tendency to ulcer- 
ate, as well by their situation, which is far less distinctive than in the 
case of leucokeratosis of the mouth. A history of infection and of 
symptoms of the disease in other regions of the body would usually 
indicate the nature of the process. 

The only malady likely to be confounded with leucokeratosis of the 
mouth is lichen planus ; and it is important to note that some confusion 
exists on this point in several descriptions of the two diseases. 

In lichen planus of the inside of the lips there may be recognized 
over the tongue, the palate, and other parts, dents, smooth or fissured 
plaques, rings, festoons, linear striae, or disks covered by a silver-whitish 
pellicle. It is clear that the distinction between these and leucokera- 
tosic lesions is in a high degree obscure, and for the present the most 
that can be done is to search with special care for other symptoms of 
disease upon the cutaneous surfaces of the body pointing to either 
lichen planus or to syphilis. 

The Treatment of leucokeratosis of the mouth is first by abstention 
from all local irritants (tobacco ; highly spiced, heated, acetous, and 
iced particles of food and drink), by the care of the teeth, and by the 
employment of soothing sprays or lotions containing potassium chlorate, 
boric acid, balsam of Peru, iodized phenol, myrrh, borolyptol, or muri- 
ated iron. 

36. 



562 NEW-GROWTHS. 

Silver nitrate may be applied to any ulcerated or fissured points, 
both in solution and by sweeping the solid crayon over the surface. 
The French make use of the salicylates in the same way. 

Destruction or removal of the lesions may be secured by the employ- 
ment of caustics, chemical or galvano-cauteric ; by erasion with a 
curette ; or by surgical ablation. When practicable, the burr of the 
dental engine may be used after injection of cocaine muriate. Where 
the patches are not too dense and extensive this has generally been 
productive of good results. 

Sherwell x reports complete removal of the patches by the use of 
undiluted liquor hydrargyri nitratis. The mouth is stuffed with cot- 
ton to protect adjacent parts ; the solution is applied and allowed to 
remain from fifteen to twenty minutes, after which it is neutralized with 
sodium bicarbonate. If necessary, the application may be repeated two 
or three times at intervals. 

Pierce 2 was successful in one case after rubbing into the patches 
pyoktanin-blue, followed immediately with an aqueous solution of 
anilin-oil. The applications were made daily for three months. 

The Prognosis is fairly favorable in the case of all subjects of the 
disease who consent to deny themselves absolutely the luxury of tobacco- 
usage in every form, and who can follow a prescribed hygienic and 
medicinal course. For all others there is danger of epithelioma. 

MYOMA. 

(Gr. ftvav, muscle.) 

Cutaneous myomata are divided by Besnier 3 into two classes : 
simple myoma, or liomyoma; and dartoic myoma. 

Daetoic Myoma is much more common than is the other form, 
and is of chief interest to the surgeon. It is usually single, though 
occasionally multiple, and occurs most frequently on the mamma?, the 
labia majora, the penis, and the scrotum. The tumor develops slowly, 
finally attaining a size varying from that of a small nut to that of an 
orange, and may be sessile or pedunculated. In most cases reported 
pain has been slight or absent, though it was marked in a case reported 
by Virchow. Under the influence of cold and local irritation the tumor 
usually contracts or may show a slow vermicular motion. Some of 
these tumors are composed almost entirely of non-striped muscle- 
fibres, others are mixed with other tissues to form a Fibromyoma, an 
Angiomyoma (Myoma Telangiectodes), or a Lymphangiomyoma. 

Simple Myoma is rare, only eighteen cases 4 having been reported. 
Its lesions are usually multiple and occur most frequently on the 
upper extremities, affecting chiefly the extensor surfaces, but they 
may occur on other parts of the body. They begin as minute round 

1 Jour. Cutan. and Ge,n.-Urin. Dis., 1899, p. 185. 

2 Chicago Med. Recorder, xii.. p. 178. 

3 Annal. de Derm, et de Syph., 1880, p. 25 ; and Besnier-Doyon translation of Kaposi, 
vol. ii., p. 346, with reference to all reported cases. 

4 For a resume of all cases reported to date, see Crocker, Brit. Med. Jour., Jan. and 
Feb., 1897 ; and Roberts, Ibid., April, 1900. 



ANGIOMA. 563 

or oval macules or papules which develop slowly to the size of a small 
pea or bean, occasionally becoming larger. At first readily effaced with 
the finger, later they become firm and elastic to the touch, are usually 
limited to one or two regions of the body, where they appear in patches 
without definite arrangement or grouping, and are pinkish, reddish, 
or of the color of the normal skin. In the beginning the growths are 
usually insensitive, but in most cases after slow evolution become painful 
on pressure and in some instances they are the seat of paroxysms of 
severe pain which occur spontaneously and at irregular intervals. 
Nearly all the cases reported have been in elderly people and in men. 
Some of the tumors may undergo involution, but usually they tend to 
increase in size and in number. Histological examination shows that 
they are limited to the derma proper, and are composed chiefly of 
unstriped muscle-fibre mixed with some elastic tissue, w T ith a few ves- 
sels and nerves, and are frequently developed about the hair-follicle. 
They are probably derived from the erector pili muscles. 

In a case under observation multiple pinhead- to large bean-sized 
congenital tumors were situated near the sterno-cleido-mastoid muscle 
of a girl nineteen years old. These were exquisitely sensitive to pres- 
sure, were capable of slight vermicular motion when irritated, and 
examination of the largest, after removal, disclosed smooth muscular 
fibres, and, in small proportion, terminal filaments of cutaneous nerves. 

The Diagnosis in well-marked cases is not difficult, but in some 
instances the recognition of the disease must depend upon a micro- 
scopical examination. Myomata have been mistaken for xanthoma 
tuberosum, for keloid, for lymphangioma tuberosum multiplex, and for 
neuro-fibroma. The last-named tumors are painful from the begin- 
ning, and usually develop in the course of a nerve. 

The only successful Treatment is by excision. 

ANGIOMA. 

(Gr. ayyelov, vessel.) 

Angiomata are divided into those composed of blood-vessels and 
those formed of lymphatic vessels. The former are much more fre- 
quent and variable in character. 

Symptoms. — Blood-vascular new-growths occur in three forms : 
nsevus vascuiosus, telangiectasis, and angioma cavernosum. 

Nsevus Vascuiosus (JNLevus Flammeus, Nsevus Sanguineus; 
I Ger., Gefassmal). — This term is limited to those vascular anomalies 
1 of the skin which are either visible at birth or become developed in a 
brief period thereafter. They commonly occur as irregularly outlined 
or distinctly circumscribed, smooth spots, patches, or maculations, 
f varying in color from light red to deep violet and port wine, and are 
either flat or very slightly elevated above the general level of the in- 
tegument. From this type wide variations are noted, in the develop- 
ment of pea-sized papules or tubercles to tumors even of large size ; 
pulsating and aneurismal in character ; spongy or relatively firm ; 
fading or more rarely persistent under pressure ; superficial or deeplv 
seated ; venous or arterial in their connections ; single or numerous ; 



564 NEW-GROWTHS. 

and in either case limited to a small area or involving a relatively 
large surface. They are of most common occurrence upon the head, 
but are seen also on the trunk and extremities. Often they are the 
sole lesions of the skin present in a single individual ; in other rarer 
cases they complicate moles, warts, and lymphangiomata. 

The surface of these lesions is usually smooth, though it may be 
rugous. They are generally compressible, losing their habitual color 
when the blood is forcibly pressed out from the loose meshwork of 
vessels of which they are composed, and becoming turgid and deeply 
tinted when the blood is driven into their tissue, as in the face in the 
act of sneezing. 

The course of these lesions varies with their essential character. Of 
the simpler varieties, the larger number increase somewhat in extent 
and development till they have attained a maximum size, and then 
they either persist indefinitely or accomplish a species of involution 
after agglutination of the vascular walls, leaving a whitish, cicatriform, 
occasionally pigmented surface. Others extend indefinitely, involving 
the neighboring mucous surfaces, subcutaneous tissue, and deeper 
structures, forming vast tumors, destructive not only by their tendency 
to extension, but by their mechanical effect. Fortunately, these ex- 
treme developments are rare. Much more commonly vascular nsevi 
furnish the forms known as " port-wine mark n or " claret-stain," 
which awaken no subjective sensations, and are usually of clinical im- 
portance in consequence of the marked disfigurement which they 
produce. 

Occasionally, especially in the case of infants but a few days old, 
phagedena or gangrene will suddenly occur in these patches without 
appreciable cause (probably in consequence of the occurrence of throm- 
bus), and the entire tumor will be removed, the line of demarcation 
of the destructive process being exactly limited to the border of the 
angiomatous tissue. The scar resulting is superficial, and becomes 
smoother in course of time. In this way may occur spontaneous cure 
of nsevi of considerable size existing on the head and genitalia of 
infants. 

Telangiectasis (N^vus Araneus, "Spider Cancer"). — Tel- 
angiectases are acquired dilatations often combined with new forma- 
tion of blood-capillaries, which appear at periods of life other than at 
birth or a few months later ; and are, therefore, distinct from the con- 
genital forms of the disease. They are commonly first observed in 
adult life and occasionally multiply with advancing years. They 
occur in diffuse and localized forms. 

Diffuse, generalized telangiectasis is exceedingly rare. Hillairet and 
Vidal have each observed one such case in individuals of both sexes ; 
the condition being apparently due to systemic disturbance. 

The localized forms are betrayed by the occurrence of flat or slightly 
elevated, pinhead- to pea-sized macules ; diffuse patches ; linear ramifi- 
cations of individual vessels ; or contorted congeries of a plexus of the 
latter, all exhibiting the variations in color of nsevi vasculosi, but 
usually of pinkish or violaceous hue. They are unaccompanied by 
subjective sensations, 'are evidently non-inflammatory in character, and 



ANGIOMA. 565 

are simple or multiple lesions chiefly upon the face, but also upon the 
neck, the back of the hands, the thighs, and other parts of the body. 
They are not rarely observed in connection with other diseases. Thus 
they occur in the vicinity of the lesions of lupus erythematosus, sclero- 
derma, acne rosacea, cicatrices, and about the contour or over the sur- 
face of many malignant tumors. They may, therefore, have either an 
idiopathic or symptomatic character. 

The term Rosacea, as distinguished from acne rosacea, is employed 
to designate that condition in which the skin, of the face particularly, 
is affected with dilatation of the capillaries. (Consult in this connec- 
tion the chapter on Acne Rosacea.) 

The conditions here described as nsevus vasculosus and telangiectasis 
are displayed in forms which, apart from the question of congenital 
origin, offer the widest differences and the most bizarre combinations. 
The so-called nsevus flammeus, naevus araneus (spider-cancer), nsevus 
vinosus, " mulberry-," " strawberry-," and "mother-marks " are all 
examples of these combinations. 

The lesions may be congenital. There is no proof that they are 
due to antenatal maternal impressions, though the influence of the 
nervous system in deciding the area of limitation of the congenital 
forms is exceedingly distinct, as, for example, the definition of a port- 
wine mark in the skin-area supplied by one supraorbital nerve. 

Angioma Cavernosum (Tumor Caveexosus). — Cavernous angioma 
is distinguished from the angiomatous lesions described above by the 
peculiarities of its formation. It consists of a dense framework of new- 
formed connective tissue, inclosing loculi or chambers of varying 
capacity, containing blood and communicating not only with each 
other, but with the larger vessels in the vicinity. Whether these 
blood-spaces originate in the fibrous felt-work of the derma which 
later establishes a vascular connection, or in the vessels themselves, or 
whether they are constituted by a mechanical dilatation of such vessels 
in consequence of a neAV-formed connective tissue in the adventitia, has 
not been determined. According to Virchow, the lesions arise gen- 
erally from coalescence and dilatation of vessels. Other causes are 
explained by the earlier formation of a contracted cicatricial tissue by 
which vascular distortion occurs. (Rindfleisch.) 

Cavernous angiomata are said to be rarely congenital, developing 
soon after birth, and to be both superficial, deep, circumscribed, and 
diffuse. Sometimes they originate from a nsevus or superficial telan- 
giectasis. Often when fully formed they are distinctly encapsulated. 
The diagnosis is between cysts, fibromata, lipomata, and sarcomata. 
The rarity of this affection in dermatological practice may be explained 
by the surgical features of many cases. In five years no instance of 
angioma cavernosum was reported in the statistical tables of the Amer- 
ican Dermatological Association. 

Etiology and Pathology. — The causes of the several forms of 
angioma named above are obscure. The symptomatic telangiectases 
are undoubtedly to be explained by obstruction to the circulation occa- 



566 NEW-GROWTHS. 

sioned by the tumor or other lesion to which they are accessory. The 
foundation for the vulgar belief that maternal impressions are respon- 
sible for the so-called " mother's marks " is very slight. The reputed 
resemblance of the latter to various flowers and fruits generally requires 
for its recognition a stretch of the imagination. 

Anatomically, these lesions are recognized as due to dilatation and new 
formation of venous and arterial capillaries in the superior portions of 
the derma, the vessels of the newly formed plexus freely communicat- 
ing with each other. Generally there is a simultaneous new formation 
of connective tissue constituting the framework of the growth, which 
varies considerably in the different forms of the disease. Lobules con- 
stituted of coils of capillary vessels are often separated by it into dis- 
tinct masses. According to Heitzmann, the large spaces of angioma 
cavernosum imitate the structure of the corpora cavernosa of the penis, 
and are filled with venous blood, being separated from each other by 
a scanty fibrous connective tissue. 

Billroth states that the new formation has its origin in the vascular 
network surrounding in basket-like forms the fat-lobules, follicles, and 
glands of the skin. Embryonal, vascular growths spring from these, 
and as they multiply and develop are enforced by proliferation of 
fibrous, connective, and muscular tissue. The color depends largely 
upon the preponderance of arterial or of venous capillaries in the new 
formation. 

Diagnosis. — The ordinary lesions of angioma are readily recognized 
by their color, size, shape, and obvious vascular constituents. Ander- 
son calls attention to the importance of differentiating encephalocele 
due to the failure of ossification of the ethmoid and frontal bones at 
the root of the nose. Operations upon such tumors supposed to be 
angiomatous in character have resulted fatally. Lobulation, great dis- 
tention (when a child is crying), a superficial rather than deep and com- 
plete vascularization of the smooth and glossy skin of the tumor, and 
a double pulsation, all point to frontal encephalocele. 

Treatment. — The treatment of this group of new-growths is, in 
general, limited to a series of local surgical procedures. These opera- 
tions all have in view either the destruction of the new-growth or the 
artificial production of an inflammation, in order to obliterate, to an 
extent sufficient to interfere with the transmission of the blood-current, 
the lumen of the capillaries of which the neoplasm is composed. 

First among these methods is electrolysis. One or a set of several 
fine cambric needles, with their points at the same plane, are connected 
with the negative pole of an ordinary zinc and carbon battery of ten 
to twelve cells. The points of the needles are quickly passed into the 
tissues, and there held for a period of between ten and thirty seconds, 
according to the effect produced after completion of the circuit, with a 
current of from one to two milliamperes. The new-growth is thus 
blanched in the vicinity of the needles, this effect disappearing in the 
course of a few moments. 

In about three weeks the curative result of the operation becomes 
apparent. According to Fox, 1 of New York, the objections are that 

l N.*Y. Med. Record, Feb. 18, 1882, p. 188. 



ANGIOMA. 567 

the operation is sometimes painful and tedious, and may occasionally 
result in the production of suppuration, superficial sloughs, minute 
keloid-like elevations, vascular nodules, depressed scars, or superficial 
ulcers. In scores of cases, however, there is no production of re- 
sults worse than the original disfigurement. Usually the success is 
complete. 

The method of Sherwell l is by multiple puncture with a set of fine 
needles in a holder similar to that described above. These are dipped 
in a 25 to 50 per cent, solution of chromic acid, and then made to 
penetrate the part to be attacked. The bleeding is readily arrested 
by pressure, and then the patch is covered with several layers of flexile 
collodion. This procedure is of value in circumscribed patches of super- 
ficial character and relatively limited area. By it one can succeed in 
removing port-wine marks with the result of producing a somewhat 
irregular cicatriform tissue much less disfiguring than the original 
blemish. 

Squire's operation is done upon previously frozen patches with the 
aid of an instrument which destroys the vessels by making numerous 
crossed and closely spaced linear incisions, parallel to each other and 
in a plane obliquely directed to that of the integument. Here also 
bleeding is arrested by pressure, exerted before the circulation is re- 
stored. The operation has been, in hands other than his own, attended 
at times with unsatisfactory results. 

Sodium ethylate, a compound in which the radical ethyl in ethylic 
alcohol is united with sodium, is a caustic recommended by Richard- 
son 2 in the treatment of nsevus. It is applied by means of a brass 
rod. A first application usually results in the formation of a dense 
crust under which the nsevus contracts ; and repeated applications are 
made at intervals of a few days till the desired result is obtained. 
The sodium ethylate should be pure, and the crusts should not be dis- 
turbed till they fall spontaneously. In one case there was a persistent 
redness of the resulting scar that was decidedly open to objection. 

Other methods employed are the ligature when practicable ; puncture 
with incandescent needles ; topical application of caustics other than 
those named above, such as potassium hydroxide, nitric and carbolic 
acids, and corrosive sublimate ; and total excision, the latter being 
practicable in relatively small growths. Larger growths also can be 
removed and the surface covered with skin-grafts. The galvano- 
cautery and the thermo-cautery are both valuable in the destruction of 
capillaries. For telangiectasis and nsevi no larger than a pea the 
Paquelin knife is an efficient resort. The old method of multiple 
vaccination about and upon the involved area is sometimes followed by 
good results, and whether in consequence of the retraction of tissue 
under the influence of the inflammation excited, or of the destructive 
results of the suppuration induced, or of an indefinite caustic effect, is 
not clear. 

These results may be partly imitated by the induction of superficial 
pustulation and suppuration through the medium of tartar emetic and 

1 Arch, of Derm., October, 1879. 

2 Lancet, November 9, 1878. 



568 NEW-GROWTHS. 

croton-oil, methods which should be considered clumsy in the light of 
recent successes obtained by more manageable expedients. 

Injections with carbolic acid and ferric chloride in a few cases have 
been followed by fatal results, but are at times successful. 

Coombs 1 has modified somewhat the method most in vogue, by 
passing fine silver wires through nsevus-growths, and connecting the 
extremities with a Bunsen battery. When the wires are heated the 
circuit is broken, and the ends of the wires are disconnected from the 
battery and united to each other, being left in situ and covered with 
lint and plaster. The current can then be passed repeatedly without 
reinsertion of the wires, and the latter need be withdrawn only when 
the cure is complete. 

The Treatment of angioma cavernosum requires surgical interfer- 
ence. 

The Prognosis in any case of angioma rests upon the method of 
treatment adopted for its removal. In the larger number of cases the 
lesions, having attained a maximum development, persist without 
further pathological change, constituting a deformity rather than a 
disease. Physiological alterations in the color of such lesions occur 
under the influence of changes in the circulation. 

ANGIOMA SERPIGINOSUM. 

(Infective Angioma, N^vus Lupus.) 

This disease has been described and figured by Hutchinson, 2 Jamie- 
son, Lassar, Joy, White, and others. It is one of the rarer affections 
of the integument. 

Symptoms. — The elements of each group of lesions are bright- 
reddish puncta, resembling grains of Cayenne-pepper, arranged in oval 
or circular rings which are definitely outlined, and are a centimetre or 
more in diameter. The "infective satellites'' are outlying points or 
patches where the disease is spreading. This extension is usually at 
the outer border of one of the annular groups of lesions. The color 
varies from a light- to a deep-reddish hue or purple ; tints which are 
due to the vascularity of individual lesions. The color can at times 
be made to disappear on pressure. 

The parts chiefly affected are the shoulder, the leg, the elbow, the 
ear, the arm, the hand, and the chest. The disease may occur in infancy 
or adult years. Its evolution is slow, and usually unproductive of 
subjective sensations. Occasionally the tufts of dilated capillaries 
which constitute the reddish points are not grouped in a circinate or 
other special arrangement, but simply irregularly distributed over the 
affected surface. 

Etiology. — The cause of the disease is unknown. In a case under 
observation in a female infant the lesions developed as a sequence of a 
congenital nsevus of the vulva. Hutchinson has made a similar obser- 
vation. The affection has been noted more often among male patients. 
One case is supposed to have originated in violent muscular exercise. 

1 Lancet, 1881. 

2 -Arch, of Surgery, vol. i., Plate IX. 



L YMPHANGIOMA . 569 

Pathology. — The disease, being at first but obscurely understood, 
was until recently supposed to be one of the several expressions of 
lupus and was for that reason assigned one of the names given above. 
Examination of tissue removed from a patient w T hose case was fully 
reported by White, 1 which was in all points typical, reported upon 
also by Darier, Councilman, and Bowen, indicates that the disease is 
an angiosarcoma. Darier describes it as sarcome angioplastique reticule. 
The corium was found well filled with small-cell infiltrations, and these 
cells had an epithelioid nucleus. There were abundant proliferation of 
the endothelium and perithelium and a new formation of vessels. 

Diagnosis. — The disease is to be recognized by its vascular puncta 
and by their special tendency to grouping and extension through a 
serpiginous process never seen in simple telangiectases, nor in common 
forms of nsevus vascularis. 

The Treatment is by surgical ablation or destructive cauterization. 

LYMPHANGIOMA. 

In the present state of knowledge on this subject it is not always 
possible to draw sharp dividing-lines between lymphatic new-growths 
on the one side and simple lymphangiectasis on the other. It is prob- 
able that the two processes often are associated. 2 

Lymphangiectasis, uncomplicated by growth of new vessels, may 
occur in the superficial or deep lymphatics. When superficial, pinhead- 
to pea-sized, isolated or grouped vesicles form which have the color of 
the normal skin, which disappear temporarily under pressure, and which 
do not break easily, but on rupture give exit to a continuous or inter- 
mittent flow of lymphatic fluid. Elliott 3 describes a case of this kind 
in which the vesicles bordered old scar-tissue and were seemingly iden- 
tical in character with the lesions of lymphangioma circumscriptum, 
but histological examination showed them to be formed by simple 
dilatation of the lymphatic capillaries, due probably to mechanical 
obstruction. 

Lymphangiectasis of the deeper vessels often produces no change 
visible on the skin, and can then only be recognized by palpation, or it 
may be displayed in raised, irregular cords, or in chains of nodules. 
Following injuries or inflammation it may be acute, but usually it is 
chronic, and occurs most frequently on the lower extremities and in 
parts in which the return current of the circulation is in some way 
impeded. The skin may become the seat of soft nodules which may 
rupture and form lymphatic fistules ; but more frequently the greatest 
changes occur in the deeper structures, resulting in elephantiasis, in 
phlegmon, or in lesions of periosteum and bone, the skin of the affected 
region being cedematous, infiltrated, ulcerating, or cicatricial. 

Simple Lymphangioma may occur upon any part of the body in 
the form of circumscribed, elastic tumors made up of enlarged lym- 

1 Jour. Cutan. and Ven. Dis., 1894, p. 505. 

2 For review of literature of the subject, consult Francis, Brit. Jour, of Derm., 1893, 
and Koberts, Ibid., 1897, p. 309. 

3 Jour. Cutan. and Gen.-Urin. Dis., 1894, p. 137. 






570 NEW-GROWTHS. 

phatics which are the result partly of dilatation of previously existing 
vessels and partly of new-formations. The skin over such tumors 
may be unchanged or it may be reddened and thickened. In more 
extensive cases there is hypertrophy of the surrounding tissues as in 
deep-seated lymphangiectasis. Many of the diffuse forms of lymphan- 
gioma constitute firm or lax tumors of such size as to be termed 
Elephantiasis Lymphangiectatic a or Pachydermia Lymphang- 
iectatica. These tumors often contain large lymph-filled sacs or 
lacunae, enveloped in hypertrophied muscular and connective tissue, 
and an oedematous integument. Some of the elephantiasic deformities 
of this character are fully as enormous as the extreme distortions of 
elephantiasis proper. Upon the tongue the condition is called Mao 
roglossia, and upon the lips Macrochilia. 

Lymphadenectasia is a name given by Virchow to tumors usually 
in the axillary or inguinal regions, where the lymphatic vessels in the 
lymphatic glands dilate or multiply so as to form large tumors. The 
lymph-scrotum due to the presence of the filaria sanguinis hominis is 
described elsewhere. 

Simple lymphangiomata may be congenital. Their cause is un- 
known. It is supposed that they are produced by toxic or other irri- 
tating influences. They are often the seat of a recurrent, circumscribed 
inflammation of erysipelatous type. Anatomically the lesions are 
found to consist of greatly developed lymphatic vessels and spaces, 
lined with epithelium and enveloped in small-celled connective tissue- 
stroma. The treatment, of the larger lesions only is surgical. 

Cystic Lymphangioma belongs to the domain of surgery. It 
occurs in the form of multilocular cysts, usually congenital in origin 
and most frequently situated in the neck. 



Lymphangioma Circumscriptum. 

(Lymphangioma Cavernosum, Lymphangiectodes, Lymphan- 
gioma Capillare Varicosum, Lupus Lymphaticus. 
Ft., Angiome Cystique.) 

This is practically the only form of lymphangioma entitled to spe- 
cial consideration by the dermatologist. It is a rare form of skin-dis- 
ease and is well illustrated in the case reported by Morris. 1 

Symptoms. — The characteristic lesions are small, deep-seated ves- 
icles generally described as resembling frog's spawn. They are usu- 
ally closely crowded in irregularly shaped groups from eight to twenty 
millimetres in diameter with normal skin between. These groups have 
no regular arrangement or distribution. There are sometimes a few 
scattered vesicles about or between the borders of the groups which 
may coalesce to form new patches. There are usually several of these 
groups, but they are confined, as a rule, to one small region of the 
body. The most common sites, according to Francis, who has collated 
reports of twenty-eight cases, are on the upper parts of the extremities. 

1 Internat. Atlas of Eare Skin-diseases, 1889, No. 1. 



LYMPHANGIOMA. 571 

In a large majority of the cases reported the lesions occurred on the 
left side of the body. 

The vesicles are deep-seated with thick walls, and vary in size from 
that of a pinhead to that of a small pea. The newer and scattered 
vesicles may be colorless or have a yellowish or pinkish tinge, but the 
skin over the older lesions may hypertrophy and produce growths that 
are easily mistaken for warts, and may even result in decided warty 
projections. Other lesions may be more or less covered with telangi- 
ectases and vascular dots or tufts which may be present to such an ex- 
tent as to obscure the primary vesicle-formation. When punctured the 
lesions give exit to clear, colorless fluid, which at times may be tinged 
with blood, the result of hemorrhage into the vesicle. 

In some cases the lesions and skin about them become the seat of a 
recurrent inflammation of erysipelatous type, 1 such as not infrequently 
complicates other forms of lymphangioma. Probably as a result of 
these attacks of inflammation there are often infiltration, thickening, 
and even true hypertrophy of the deeper layers of the skin, forming a 
sort of local elephantiasis. 

The disease in most cases reported began in early childhood and 
developed very slowly, often remaining stationary for years. In but 
one case has spontaneous involution been reported. 

Etiology. — As the disease usually makes its appearance in infancy 
or early childhood, it is probable that its origin is due to some con- 
genital defect. It has appeared a number of times in connection with 
nsevi. It has followed surgical operations, bordering the scars pro- 
duced by the operator; it is possible that such cases are simple lymph- 
angiectases of the capillary vessels due to blocking of the larger 
channels by the scar-tissue. 

Pathology. — The vesicles, or cysts, are found on section to be situ- 
ated in the upper part of the corinm. These cysts are shown to have 
an endothelial lining and are undoubtedly dilated or newly formed 
lymph-capillaries. Immediately about the cysts and dilated lymphatics 
in an early uncomplicated lesion Bowen found considerable infiltration 
of round cells, but no other changes in the corium, while the epidermis 
was slightly thinned. In older lesions there is hypertrophy of the 
epidermal layers, and sometimes of the deeper parts of the corium. 
In other cases there are more or less dilatation and apparently new 
growth of the blood-capillaries. This change in the blood-vessels may 
be slight or so marked as to form the chief feature of the disease both 
clinically and pathologically. In consequence, confusing reports have 
been made by different observers regarding the structure and origin of 
these growths, many of which seem entitled to the name of hemato- 
lymphangioma. 

Treatment. — The treatment is surgical. The growth may be re- 
moved by excision or with the cautery. Electrolysis has been of service 
in some cases and should be given further trial. In several instances 
the lesions have recurred after complete removal. 

1 Cf. White's report, Jour. Cutan. and Gen.-Urin. Dis., 1894, p. 47 ; also Bowen's 
article in Twentieth Century Practice, vol. v., p. 687. 



572 NEW-GROWTHS. 

XERODERMA PIGMENTOSUM. 

(Angioma Pigmentosum et Atrophicum, Atrophoderma Pig- 
mentosum, Dermatosis Kaposi, Melanosis Lenticularis 
Progressiva, Liodermia cum Melanosi et Telangiectasi.) 

More than seventy-five eases of this disease have been recorded ; 
and these by Kaposi, Glax, Crocker, Vidal, Pick, Neisser, Geber, 
Taylor, Duhring, White, and others. Tables have been compiled by 
Kaposi, 1 Archambault, 2 and Lukasiewicz, 3 including seventy-three 
cases. The disease results ultimately in a diffuse idiopathic cutaneous 
atrophy, but this condition is preceded by a general hyperemia with 
vascular dilatation ; the production of numerous punctiform, bright- 
red, pinhead- to pea-sized, flat or raised telangiectases ; and dissemi- 
nated, brownish, and yellowish-brown macules, varying in extent, 
between which form superficial, whitish and glossy, atrophic depres- 
sions, like the cicatrices of variola. The regions involved are, as a 
rule, the exposed surfaces, viz., the face, ears, neck, shoulders, and 
chest to the third ribs and even to the lumbar region, the arms and 
back of the hands, occasionally the legs and the dorsum of the feet. 
The yellow r ish-brown, freckle-like spots are soon after their appearance 
intermingled with superficial cicatriform depressions, either unnatu- 
rally whitish in hue or of the color of the normal skin. The puncti- 
form or linear dilatations of the vessels, usually numerous, furnish a 
striking contrast with the freckled and pigmented parts. In some 
parts the skin is of parchment-like thinness ; in others it is furrowed, 
laminated, and split, as if dry or brittle. It is usually deprived of its 
normal suppleness, is retracted, and is often attached to the subdermic 
tissue. 

The disease commonly begins in the first or second year of life, and 
progresses continuously. The order of occurrence of the lesions as 
given by Kaposi is the freckle-like pigmentations, surmounted in the 
course of a year or two by telangiectases ; then a gradual disappearance 
of the latter and occurrence of the cicatriform depressions ; finally a j 
diffuse atrophy of the skin. New pigment-spots continue to form, so 
that a given case usually presents all types and grades of lesions. 
Observers of these cases differ somewhat as to the order in which the 
several lesions of the disease appear ; and Duhring thinks it possible 
that no definite order is observed in the evolution of the symptoms. 
White, in the case under his observation, could trace no transforma- 
tion from a pigment-macule into a telangiectatic lesion. 

The melanosis is at times so uniform and diffuse as to suggest the 
dark tints of the Spanish skin, as in White's case, with a dense spat- 
tering of a still darker hue and a blackish scrotum. The atrophic or 
leucodermic condition of the skin may coexist with the melanoderma, 
and present large well-defined areas totally devoid of pigment where 
the skin may have a pinkish tint. The ears may thus come to 

1 Wien. med. Woch., 1885. 

2 Dermatose de Kaposi. Bordeaux, 1890. 

3 Arch: f. Derm. u. Syph., 1895, Band xxxiii., S. 37. 



XERODERMA PIGMENTOSUM. 573 

resemble tanned sheepskin. The skin soon becomes furrowed, con- 
tracted, and as dry as parchment ; and thus is readily developed an 
eczema or a superficial degeneration, including ulceration. A species 
of furfuraceous desquamation also occurs in patches. The faces of 
most patients exhibit a peculiar checkered appearance, from the uni- 
form dissemination of the pigmented macules over the skin. Ectro- 
pion, with ulcerative keratitis, may occur. In the course of years 
verrucous growths appear, starting usually in the pigmented spots, 
/ either epitheliomatous, sarcomatous, or angiomatous in character. They 
i may be single or many ; may be confined to the skin or develop in 
the viscera ; and usually lead to fatal results in a few or many years. 
Often the general health seems, for long periods of time, to remain 
: unimpaired, the subjective sensations being slight Both sexes in 
\ early life seem equally predisposed to this disease, though the large 
] number of members of single families affected with its symptoms 
3 indicates the importance of predisposition and heredity in point of 
ij etiology. It is usually manifested before the third year of life. 

Pathology. — The disease probably begins as a proliferation of con- 
J nective tissue in the papillary layer, with involvement also of the 
vascular endothelium, followed in some points by retraction and in 
j others by both ectasis and new formation of vessels. By Kaposi, who 
I has the honor of first naming and describing the disease, the irregular 
•I accumulation of pigment is regarded as consecutive to the vascular 
, changes. The rete-pegs extend deeply below ; there are ectasis of the 
glands and epithelial degeneration. 

By the French the disease is generally regarded as a pigmentary 
I epithelioma or " epitheliomatous lentigo " (Quinquaud), the connection 
I between the neoplasm and the pigment-anomaly being regarded as 
similar to that recognized in melanotic sarcoma. 

The Etiology of the disorder is exceedingly obscure. A congenital 
predisposition is shown by the occurrence of several cases in one fam- 
l ily ; most of the patients have been females. There is a very singular 
disposition of the disease to select one sex in different families. In 
forty-three cases collected by Kaposi there were six times, two ; four 
times, three ; and once, seven brothers or sisters affected with the dis- 
ease. The age of the patients first exhibiting the disorder is from the 
first to the second year. Schwimmer has reported a case occurring 
in the thirty-fifth year. Unna believes it possible that the action 
of light upon the skin has an influence in the production of the 
disease. 

The Diagnosis is chiefly from scleroderma, but as the latter always 
begins with induration of tissue, and as xeroderma pigmentosum 
always begins with either erythematous or pigmented spots, the 
f distinction is clear. In a case of scleroderma, too, apart from its 
onset at a later period of life, the pigmentations are late rather than 
early ; and the telangiectases are found in circumscribed scleroderma 
j as a violet-tinted border about a patch ; never as points, nodules, and 
stellate markings interspersed among pigmented spots and depressions. 
Lepra maculosa is characterized by marked anaesthesia in and about 
the pigmented and non-pigmented areas ; further, its course is toward 



574 NEW-GROWTHS. 

mutilations of the body, and even at an early period there may be 
vesiculation. 

The Treatment of the disease is limited to amelioration of the con- 
dition of the skin by means of local applications varied to meet the 
indications as they arise. Surgical ablation of tumors, with electrolysis 
of smaller lesions, may be employed to prevent or postpone a fatal 
termination. 

The Prognosis is in the highest degree unfavorable, as most of the 
patients succumb to marasmus in from ten to twenty years. 

RHINOSCLEROMA. 

(Gr. pig, or piv } the nose, and OK?ij]p6g } hard.) 

Symptoms. — A knowledge of this rare disease, first described by 
Hebra and Kaposi in 1870, has been obtained from a study of some 
one hundred cases observed by these and other authors. The follow- 
ing is a concise description of the malady as thus presented. 

The disease commonly begins in the septum or a single ala of the 
nose, without inflammatory symptoms. The involved parts slowly 
enlarge, and become finally as dense as ivory. The individual lesions 
are flat patches, or elevated and circumscribed nodules, papules, and 
tubercles, painful upon pressure, movable to a certain extent over 
underlying tissues, and covered either by a normal integument, or by 
a light or dark-red, shining, vascular epidermis. Neither hairs nor 
glands are discernible over the lesions. As the disease progresses the 
ala3 become enlarged, flattened, and so indurated that they cannot be 
pressed together, while respiration may be impeded by stenosis of the 
nares. The process may extend to the neighboring parts, involving 
thus the upper and lower lips, gums, velum, epiglottis, larynx, trachea, 
and jaws, the teeth meanwhile falling from their sockets and the soft 
palate becoming in some cases perforated. Involution of the process 
has not been observed, and the lesions do not degenerate by ulceration. 
Max Zeissl, 1 however, reports a case in which there was ulcerative 
destruction of the entire left nostril, as well as of the tip and right 
ala of the nose. Occasionally superficial excoriations have occurred, 
but very rarely a diminution in the consistency of the mass. The dis- 
ease pursues a chronic course, requiring years for its development ; and 
though the affected parts are painful on pressure they are otherwise 
not the seat of subjective sensation. 

Etiology and Pathology. — The disease is observed between the 
fifteenth and fortieth years in persons of all social conditions and in 
individuals of both sexes, free from syphilitic, strumous, tubercular, 
and other cachexias. 

Kaposi originally observed, as anatomical lesions of the disease, a 
dense infiltration of the corium and its papillary layers with small, 
closely packed elements, which he recognized as a true new-formation. 
He considered this as analogous to small-cell sarcoma, inasmuch as 
Mikulicz, Geber. and Billroth have seen some of the elements of the 

- 1 Wien. med. Woch., 1880, p. 621. 



RHINOSCLEROMA. 575 

neoplasm undergoing the osseous transformation common in sarcomatous 
tumors. 

In 1882, however, A. von Frisch, after examining tissue removed 
from lesions of rhinoscleroma in twelve patients, found in the cells 
and between them in the interpapillary fissures of the connective tissue 
bacteria distinctly rod-shaped, one and one-half times longer than 
broad. These germs were successfully cultivated, but experimental 
inoculations with culture-fluids thus obtained were negative in results. 
Dreschfield 1 found in sections of tissue obtained from a patient of 
Payne's numerous bacilli less slender and smaller than those occurring 
in tuberculosis and with slightly thickened extremities. These were 
unlike those exhibited at the Berlin Congress by Paltauf, who con- 
siders them closely related to Friedlander's pneumococcus. Barduzzi, 
Pellizari, Cornil, Alvarez, Lustgarten, and others have added to the 
evidence in favor of the parasitic nature of the disease. 

The bacilli are found encapsulated in a colloid-like substance and in 
series of two and fours. They occur in the lymphatic ganglia, in the 
giant-cells of the neoplasm, and in protoplasmic masses corresponding 
to these or to their degenerate nuclei. Pawlowsky, of Kieff, in 1890, 
demonstrated that the bacilli of the disease are pathogenic for the 
loAver animals. Besnier and Doyon, however, pointing to the limi- 
tation of the disease to Austria, reject a parasitic origin for the disease. 
Mibelli, who has given the subject careful study, found two kinds of 
cells characteristic of the process : one a dropsical and the other a 
colloid cell. He thinks these types are the result not of cell-degenera- 
tion, but of the presence of zooglea, a mucous substance produced by 
the bacilli. 

Diagnosis. — The disease can hardly be mistaken for another in con- 
sequence of its situation, the disfigurement it occasions, the ivory-like 
elasticity and induration of the affected parts, and the rarity of ulcera- 
tive degeneration. As distinguished from syphilis, it is known to be 
unaffected by specific medication. Since rhinoscleroma, however, has 
been by some writers assumed to be a form of syphilis, it is need- 
I fill to distinguish clearly between the two. But as in the former 
affection there is rarely softening of the ivory-like induration, much 
less ulceration, which is common in syphilitic gummata, the distinction 
|is tolerably clear. From the variety of acne rosacea of the nose known 
las rhinophyma, rhinoscleroma is readily differentiated by the softness 
i and compressibility of the acneiform affection and its evident vascular 
and glandular composition. 

The ulcerations of epithelioma have a more circular outline, a more 
elevated edge, and occur in persons of a more advanced age. Keloid, 
! if found in the situation of rhinoscleroma, does not ulcerate. 
J Treatment. — The method of relief thus far employed is a total or 
partial extirpation of the neoplasm. Kaposi speaks of dilatation of 
the nares, where there is actual or threatened nasal occlusion, by means 
of laminaria and compressed sponge. Both excision by the knife and 
destruction by caustics have been found to secure merely temporary 
benefit, as the growth is reproduced with rapidity. 

1 Brit. Med. Jour., October 24, 1885. 



576 NEW-GROWTHS. 

Prognosis. — The future of the patient is grave. The disease riot 
only persists and recurs after operative interference, but may endanger 
life by obstruction of the nostrils. ZeissPs case proved fatal ten years 
after the disease first appeared. 

TUBERCULOSIS CUTIS. 

Tuberculosis is one of the most common, formidable, and destruc- 
tive of the great scourges of the human family. It may attack either 
primarily or secondarily any organ or tissue of the body. The skin 
is not rarely the seat of its ravages, and when extensively involved the 
results are in the highest degree disfiguring and repulsive. 

The consequences of tuberculous invasion of the skin are usually 
declared early in life, because in those periods the skin is most easily 
invaded, and also because at these ages the habits and environments of 
the individual are conducive to the occurrence of the accident. Tuber- 
culosis of the skin may be the result of general infection in the body ; 
or may, on the other hand, be the starting-point of such infection. In 
either event the disease is always originally acquired by infection and 
not by inheritance. Children are rarely, if ever, born tuberculous. 
The coincidence of several members of one family exhibiting evidences 
of the disease is most readily explicable by the opportunities for infec- 
tive accidents furnished in such families. 

In the pages which follow no attempt is made to revert to the 
remarkable and instructive history of the gradual acquisitions of science 
on the subject of this disease. Neither within these limits is it desir- 
able to indicate the several conditions which in their relations to this 
subject have been confused in the past, and the names of which have 
served as titles for chapters on cutaneous disorders. It will be sufficient 
if the results obtained from the vast and valuable labors of the patholo- 
gists and clinicians of the last decade be concisely set forth with a view 
to the simplest systematic conception of the subject. 1 

Symptoms. — Tuberculosis of the skin is conveniently studied in 
its several forms of (1) lupus vulgaris ; (2) tuberculosis verrucosa ; 
(3) tuberculosis cutis orificialis ; (4) scrofuloderma. 

1. Lupus Vulgaris. 

(Lat. lupus, a wolf. ) 

The symptoms of lupus vulgaris are both numerous and diverse, a 
fact which may account for the many names which have been applied 
to its different manifestations, and which with few exceptions are 
descriptive merely of certain external features. 

The lupous infiltrate may be limited to small areas or diffused over 
an entire region of the body. It may be first apparent in pinhead- to 
bean-sized flattened maculations (Lupus Maculosus, Lupus Pla- 

1 In the preparation of this chapter valuable aid has been rendered by the symposium 
on the subject prepared at the request of the Council of the American Dermatological 
Association, by James C. White, of Boston ; John T. Bowen, of Boston ; and George 
Henry Fox, of New York. Boston, 1892. 



PLATE XX. 




Lupus Hypertrophieus of the Face. 



TUBERCULOSIS CUTIS. 577 

nus), from which may be later developed papules, tubercles, or nodules 
of equal or somewhat greater size, rising above the general level of the 
skin and often perceptible within its mass by palpation (Lupus 
Nodosus; Lupus Tuberculatus, Elevatus, Tumidus, Nox-exe- 
dens, non-ulcerosus). 

As in syphilis in the course of which, though almost every one of 
the elementary lesions of the skin may be developed, there is a dis- 
tinct predominance of the papule and tubercle, so in lupus vulgaris 
the type of the disorder is shown in the lupous nodule, the " lupoma," 
as it is by some authors designated. 

This dull-reddish, purplish-shaded lesion, scarcely as large as half 
a pea, may be the predominant symptom of a lupous patch for a period 
of from ten to twenty years and even more. It is of a softish, almost 
boggy consistency, yielding when pressed upon firmly with a blunt- 
pointed probe and readily penetrated by a sharper instrument. The 
English compare its contents with apple-jelly. 

The changes within, about, and beneath these lesions furnish prac- 
tically the clinical pictures of lupus vulgaris. Thus there may be 
extensive oedema, thickening, hypertrophy, hyperplasia (bouffissure), 
pachydermia, even telangiectasis, and an accompanying lymphangitis 
or lymphadenitis (Lupus Hypertrophic us, Papillosus, QEdema- 
tosus, Elephantiaticus, Tumidus, Exuberans, etc.). In many of 
these cases the prominent symptom which has suggested these names 
to the older writers is in fact a simple inflammatory swelling, due only 
indirectly to the lupoid involvement of the skin, a fact which can be 
recognized after any efficient treatment of an extensive plaque of lupus 
of the face, the subsidence of the swelling being one of the most con- 
spicuous of the immediate results of the treatment. 

Involution of the lupoma, or of tissue infiltrated with lupoid cells, 
occurs by resorption of that material, by fibroid metamorphosis, and 
by ulceration. These several changes separately or together furnish 
other clinical pictures of the disease. Thus the lupus-lesion or patch 
may furnish scales, whitish, dirty, yellowish brown, or even glistening, 
the epidermis above and about becoming wrinkled. This process may 
be central or peripheral as respects patch or lesion, leaving eventually 
a cicatriform depression in the skin (Lupus Exfoliativus, Lupus 
Psoriasiforme, " Lupus- psoriasis "). When a fibrous metamor- 
phosis occurs a sclerotic mass occupies the site of the former lupoid 
tissue, which in some cases progresses to extension of the lupoid 
patch in consequence of the further production of the toxin of the 
bacilli in the site affected ; and in others produces cicatriform tissue 
resembling that left after involution without ulceration of the gumma 
of syphilis (Lupus Sclerosus, Sclereux, Fibrosus). 

In the degenerating forms of lupus, ulceration may begin by break- 
ing down the epidermis over the lupous tissue or by a more or 
less rapid transformation of patch or lesions into a cheesy semi-puru- 
lent mass of detritus. When pus is freely formed, whether super- 
ficially or deeply, crusting ensues, the debris of epidermis being entan- 
gled with the desiccated secretions. These crusts are variously colored, 
and differ in thickness with the severity of the degenerating process 

37 



578 NEW-GROWTHS. 

beneath. The oval or circular ulcers which furnish them are usually 
well denned, though irregular as to the margin, shallow, thin-edged, and 
flattish ; and their floors are dirty reddish or purplish, indolently gran- 
ulating, furrowed, hemorrhagic, or, when cicatrization is in progress, 
healthy. The destruction produced by involution of a lupous patch may 
be both by resorption and ulceration in the same subject and at the same 
time. The two processes may also coincide with an outbreak of fresh 
lupous tubercles, which later may develop at one point or another of 
the patch undergoing involution, probably from emigration of bacilli 
at the point of advance. In other cases lupus may spread by the 
formation of fresh nodules and plaques separated by islets of sound 
skin from those previously degenerated. When the ulceration advances 
it may be superficial, deep, or have other peculiarities, and be subject 
to other accidents of the ordinary process of ulceration, whence the 
names Lupus Serpiginosus, Profundus, Superficialis, Gan- 
gr^enosus, Exulcerans, Rodens, etc. Lupus Crustosus and 
Bupoides are terms descriptive merely of the incrustations which 
form in some cases. Exuberant granulations elevating the floor of the 
ulcer may produce the condition termed Lupus Fungosus, Lupus 
Fungoldes, Lupus Vegetans. Lupus Keloides indicates a cica- 
tricial overgrowth of the scar-tissue left after any one of the several 
conditions described above. 

One of the most conspicuous features of lupus vulgaris is its essen- 
tially chronic course. It requires far more time for its complete evolu- 
tion than either syphilis or carcinoma ; and in this point is best 
compared with lepra. For a quarter of a century a lupus-patch may 
be limited to a space no larger than the palm of the hand, and exhibit 
some evidence of activity during the greater part of that period. 

Lupus of the Face. — Here the first manifestation is the so-called 
primary efflorescence, exhibited on one or both cheeks, nose, or cheek 
and nose, as a dull-colored maculation or minute nodule, often long 
unnoticed, or as a finger-nail-sized, purplish thickening of the skin. 
Extension may then occur by multiplication of the lesions, or by 
spreading of the single patch, the central parts wasting or cicatrizing. 
The contracture of the irregular scars thus resulting may produce an 
ectropion of the lid or lip, and with this is often seen the " boufnssure " 
of the features already described. Crusting and ulceration may be 
conspicuous or well-nigh absent features. Gradually the subcutaneous 
tissues become involved. 

The nose, after absorption of the lupous tissue, may become shrunken 
and retracted to a miniature of its former dimensions, its tip being 
noticeably reduced to a sharp point, producing thus a characteristic 
deformity suggesting the beak of a parrot. In other cases the point 
becomes bulbous, flattened, livid, and knobbed, with a thickened sep- 
tum and distorted alse, an isolated patch or two of lupous infiltration 
showing in the neighborhood of the cheek on one or both sides. The 
last described condition may lead by degenerative processes to the first, 
but is more commonly noticed as a less severe and more localized 
involvement of the face, which may terminate, in favorable cases, 
without the severe mutilation first described. 



TUBERCULOSIS CUTIS. 579 

The subcutaneous tissue, mucous membrane, cartilages, and bones 
may be destroyed ; and in place of the nasal organ itself there may be 
left eventually two ovoid cavities in the face, separated merely by the 
posterior flange of the septum. 

Often large portions of the skin of the head (cheeks, lips, nose, eyelids, 
chin, ears, brow, and neck) become altered by the lupous growth. The 
resulting thickening produces a marked and characteristic deformity, 
reducing the openings of the mouth and lids to narrow slits, interfering 
with vision, speech, and mastication, and producing a marasmus from 
these causes alone, before there is ulceration at any point. 

The ravages of the disease are at times frightful in severity ; not 
merely in consequence of the destructive ulceration to which it tends,, 
but from the deformity left by awkward attempts at repair. The en- 
tire surface of the head may be thus converted into a hideous travesty 
of humanity, while yet its possessor is left with all vital organs and 
functions apparently unimpaired. 

The upper lip, when involved, becomes first swollen, fissured, hem- 
orrhagic, and crusted : and a granulating surface indicates extension of 
the disease to the adjacent mucous surface. Later, if the ulcer heal, 
the mouth, by contracture, is reduced to a repulsive-looking slit or 
chasm in the face, permanently retracted, and either open or closed. 
The gums, lining membrane of the lips, velum, and hard palate may 
also be granulating, eroded, or whitish, when the exfoliated epithelium 
is in situ. Ulceration and cicatrization here also produce deformities 
interfering with the function of the parts, aphonia, for example, result- 
ing from the operation of these causes in the larynx. 

Lupus of the Ears may be symmetrical in development, or affect 
but one auricle. As in eczema, a favorite point of election is the lobule, 
which, with or without tumefaction of the whole organ, becomes a 
pyriform, purplish, dependent tumor, agglutinated speedily to the 
cheek. Later, when ulceration occurs, the auricle may disappear or 
be reduced to a shrunken shell of its former state, the external audi- 
tory meatus being, by the same process, occluded. 

Lupus of the Trunk is, as a rule, more extensive and less de- 
structive than lupus of other parts. Giant areas over the loins, hips, 
and belly may be involved in superficial, serpiginous ulceration, the 
centre healing as the peripheral ring spreads. In these cases it is even 
more difficult than in others to insure cicatrization. 

Lupus of the Genital Region may occur in both sexes, and 
then, as a rule, has extended thither from affected areas of the adjacent 
integument. It is one of the rarest of the locations involved. 

Lupus of the Extremities is remarkable for its interference with 
the mobility of the smaller bones of the hands and feet, as a result of 
rigid cicatrices, and also for the production of caries and osseous ne- 
crosis. Mutilating effects are thus produced by loss of phalanges, and 
also by shortening of the hand or foot after the destruction of bone. 
Elephantiasic enlargement of such organs as the hands and feet thus 
corresponds to the livid tumefaction seen occasionally in the face. 
Thickenings, ridges, knobs, nodules, warty excrescences, ulcers, crusts, 
and callosities are often commingled, and in patients of mature years 



580 



NEW-GROWTHS. 



strongly resemble some forms of vegetating and ulcerating epi- 
thelioma. 

Lupus of the Mucous Membranes may or may not mean exten- 
sion of the disease from an affected adjacent integument. The lupous 
nodule, in consequence of warmth and moisture, is here transformed 
into a moist papillary outgrowth, or externally granulating patch which 
may ulcerate and cicatrize. The borders of such an affected area are 
well defined, and its surface is reddish and florid, quite pallid, white 
and glistening, or of a dirty grayish-w r hite color where the investing 
epithelium is loosened but not yet detached. 

The soft is more often involved than the hard palate, but these 
parts with the tongue, larynx (epiglottis, interarytenoid fold), and 
gums may be extensively invaded. Often for from two to five years 
the disorder may make no apparent advance, being limited to patches 
of red, swollen, coarsely granulating, whitish or glistening mucous 
membrane, with ulcerating and cicatricial processes slowly resulting. 
The lymphatic glands beneath the jaw and in the subclavian region 
may be simultaneously enlarged. In connection with the characteristic 
lupoid nodules grayish growths of the character of small tumors may be 
recognized in the larynx, with the result of partial occlusion of the rima 
glottidis. Patients may suffer from apical pulmonary tuberculosis, pre- 
sumed to be the result of extension of the disease from laryngeal lupus. 

Fig. 67. 




Lupus vulgaris of the leg. 

" Lupus Demisclereux de la Langue." — Leloir * pictures and 
describes the features in the case of a girl fifteen years of age, with 
lymphatic adenopathy, typical lupoid nodules about the nose, and char- 
acteristic " parrot's beak deformity " of the latter. The middle of the 
dorsal surface of the tongue displayed smooth, pea-sized and larger 
sclerotic nodules, grayish yellow, firm and softish, separated by fur- 
rows, and non-ulcerative. The palate, uvula, and larynx were involved. 
Tubercle-bacilli were recognized and cultivated in series, and inocula- 
tion of the cultures produced tuberculosis in guinea-pigs and a rabbit. 

Esthiomene (so-called " Lupus of the External Genital Organs of 
Women"). — In the year 1849 Huguier published a report of cases 

1 Internat. Atlas of Rare Skin-diseases, 1889. 



TUBERCULOSIS CUTIS. 



581 



under the title of esthiomene, which have been the basis of a concep- 
tion widely prevalent since that date, that lupus of the vulva presents 
certain peculiarities not displayed by the same disease elsewhere. The 
subject has been restudied with special care by several observers, in- 
cluding one of us, and by Taylor, of New York. Lupus is among the 
exceedingly rare affections of the external genitalia of women, and 
where existing does not in any special way differ from its manifesta- 
tions in other regions of the body. The " esthiornene" of Huguier 
and his followers is a complexus of differing disorders, including cases 
of syphilitic sclerosis, secondary lesions, and gummata ; and hyper- 
trophies of the genital organs due to chronic " chancroid," traumatisms, 
and inflammations of a simple character aggravated by filth. It is not 
known to be a tuberculosis of the vulva, though it is possible that 
some tuberculoses may have been included in the category. 

2. Tuberculosis Cutis Verrucosa. 

There are several forms of tuberculosis of the skin in which lesions, 
differing both in appearance and career from those described in con- 
nection with lupus vulgaris, have been demonstrated to be the result 
of the encroachment of bacilli of tuberculosis or their toxins upon the 
integument. The lesions exhibit for the most part a verrucous or warty 
appearance, and are well illustrated in the most distinctive clinical 
member of the group, the anatomical tubercle. In 1884 bacilli were 
first discovered in its mass, and in the year 1886 Riehl and Paltauf 
pointed out the connection of this lesion with cutaneous tuberculosis. 

(A) Verruca Necrogenica (Post-mortem Tubercle, Dissectiox- 
tubercle, Anatomical Tubercle). — Verruca necrogenica is a vesic- 
ulo-pustular or wart-like symptom of cutan- 
eous tuberculosis, situated usually on the hands, 
and resulting, for the most part, from contact 
with the bodies of the dead. 

This lesion was first named verruca necro- 
genica by Wilks. 1 It occurs on the fingers 
(especially on the dorsum of the thumb and of 
the index) of those engaged in the habitual 
handling or dissection of cadavers, and results 
from such professional contacts, from dissection- 
wounds, and from all accidental inoculations 
with tuberculous virus. Cases are reported in 
which the lesion has had a non-cadaveric 
origin. It begins at the site of an abrasion 
or wound as a vesico-pustule, with deep-seated 
base and reddish or reddish-purple areola. 
This is productive of a burning, smarting, or 
pruritic sensation. The lesion accomplishes a 
period of bursting and crusting, which may be 
followed by complete involution. Several iso- 
lated or grouped papules, nodules, or tubercles may be formed, one or a 
patch of several being subsequently covered with villosities or undergoing 
1 Guy's Hospital Reports, third series, vol. viii., p. 263. 



Fig. 68. 







Verruca necrogenica. Model, 
Guy's Mus. 193&0. 



582 NEW-GROWTHS. 

atrophic changes over an area several inches in diameter. Dermatitis 
and suppuration, very rarely ulceration, may complicate the process, 
though at times the first symptom of infection is an ulcer forming at 
the site of a cicatrix. The typical so-called " anatomical tubercle " is 
indurated and horny. A pigmented verrucous papule or tubercle very 
slowly forms, which may become fissured at one or more points. The 
characteristic lesion is the thickened, indolent, more or less pigmented 
and fissured, split-pea- to bean-sized wart, usually single, found on the 
finger of the anatomist. This may persist as an apparently innocuous 
lesion for months or years, or suddenly assume a formidable aspect. 

In other cases grave symptoms result, either in the involvement of 
the deeper tissues (subcutaneous, thecal, tendinous, periosteal), or in the 
production of erysipelas, pyaemia, septicaemia, or gangrene. Surgeons 
divide these cases into mild and acute varieties, according to the symp- 
toms exhibited. The records of the medical profession in almost every 
one of the large cities of every country contain the names of one or more 
eminent men whose lives have been sacrificed in this manner. In a 
few instances the local process has been followed by generalized tuber- 
culosis. 

(B) Tuberculosis Verrucosa Cutis (Biehl and Paltauf) (Lupus Scle- 
roses, Lupus Verrucosus, Scrofuloderma Verrucosum; Fr. y 
Lupus Papillaire Veruqueux ; Lupus Sclereux) — The lesions 
of this form of cutaneous tuberculosis occur often on the flexor aspect 
of the lower forearm, but also in other regions of the body, such as the 
integument covering the inner malleolus and the backs of the hands. 
The jJlaques are insensitive, brownish red, movable, small-coin- to 
palm-sized, single or multiple, distinctly circumscribed, ovid or scal- 
loped in outline, and usually covered with minute pustules, fine 
pointed vegetations, and thin crusts. A characteristic violaceous halo 
commonly surrounds the whole. When healing occurs a smooth and 
scaling scar results. In those cases the .papillary layer of the skin is 
chiefly involved. 

In the papillary layer of the corium the inflammation results in the 
production of numerous minute abscesses.. Caseating nodules contain- 
ing tubercle-bacilli, giant-cells, and epithelioid cells are commingled 
with the abscesses. In some cases tubercle-bacilli are numerous ; in 
others their detection is difficult if not impossible, as in verruca 
necrogenica. 

The disease is to be most carefully distinguished from cutaneous 
blastomycosis, the lesions of which it closely resembles. Here a his- 
tological examination is essential. 

The disorder is said to be especially frequent of occurrence in those 
handling the dead or living bodies of animals. 

(C) Other Verrucous Tuberculoses. — An interesting series of morbid 
phenomena is presented when, for special reasons (proximity of tuber- 
culosis of organs other than the skin, accidents of position and ex- 
posure, influences that escape detection), sites of tuberculous infec- 
tion, whether primary or secondary in order, exhibit peculiar special 
symptoms : 

Tuberculosis Papillomatosa Cutis (Morrow's type) is by some 



TUBERCULOSIS CUTIS. 583 

authors assigned to verrucous tuberculosis (B). In these cases ex- 
uberant, soft, and florid excrescences rise to the height of one or two 
centimetres above the general level, closely packed together, with indi- 
vidual elements separated by deep fissures, the whole bathed in a puri- 
form mucus concreting in dark crusts. 

Fibromatosis Tuberculosa Cutis (Riehl). — In these cases there 
is not merely a papillomatous, but often a sclerotic growth found on 
the lips, nose, cheek, or about the anus or other mucous outlets of the 
body, interspersed with verrucous lesions, vegetations, and small shal- 
low ulcers. The tuberculous masses may be in the form of tumor-like 
bodies or thickenings of the subcutaneous tissue. 

Elephantiasis Tuberculosa Cutis is a term applied to gigantic 
overgrowths of the integument complicated by lymphatic occlusion. 
In these cases there has usually been a blocking up of the lymph- 
channels by an infarction produced by leucocytes charged with tubercle- 
bacilli. 

Tuberculosis Fungosa Cutis (Riehl). — In this class of cases 
tumors form resembling those occurring in mycosis fungoides, second- 
arily infected with tubercle-bacilli from other and usually adjacent 
organs (bone, muscle, etc.), the reddish-brown nodules first formed 
increasing to the size of a hen's egg. These may surmount large areas 
of infiltration and ulceration. Beside the tumors, minute pustules, 
vegetations, and crusts may be seen. Eventually typical tuberculous 
ulcers form. 

It is chiefly important to note in this connection that accidental 
inoculations with tuberculous material produce in different cases differ- 
ent clinical results, the essential part of the process being the transfer- 
ence of tubercle-bacilli. These infections are far more common than 
is generally understood. They occur in both the young and the old. 
Fox, of London, has reported such instances at the ages of seventy-two 
and eighty-two, respectively ; and Marmaduke Shield has seen cases of 
general tuberculosis of the aged, resulting from these accidents. 

3. Tuberculosis Cutis Orificialis. 

The clinical forms included under this title are those once supposed 
to be the sole manifestations of cutaneous tuberculosis. The title 
" tuberculosis of the skin " was, in fact, applied exclusively by many 
writers to the lesions observed by Kaposi, Jarisch, Chiari, 1 and others. 
These were indolent, oval or circular, shallow, discrete, reddish-yellow, 
granulating ulcers, often covered with thin crusts, occurring about the 
mucous orifices of patients affected with pulmonary tuberculosis (lips, 
anus, and vulva) and with development of miliary tubercles in the 
adjacent mucous tract. Tuberculous lesions of ulcerative type on the 
alse of the nose, over the lips, and about the ears, have been recognized 
in association with laryngeal, palatal, oral, pulmonary, and intestinal 
tuberculosis. 

In the case of a patient in advanced pulmonary tuberculosis, lately 
seen by us, there was a tuberculous ulcer near the anus, and also a 

1 Vierteljahr. f. Derm. u. Syph. ; 1879. 



584 NEW-GROWTHS. 

well-defined patch of infiltration in near proximity, highly suggestive 
of some of the forms of lupus. 

Acute Tuberculosis of the Skin in children has been described 
under different titles (dermatitis tuberculosa acuta, tuberculose pseudo- 
ulcereuse) by Heller and Gaucher. In these cases macules, vesicles, 
bullae, papules, and pustules, terminating in deep, crusted, circinate 
ulcers, accompanied by caseation of neighboring glands, were found 
to contain bacilli ; and inoculations of cultures resulted in distinct 
tuberculous infection. These cases scarcely justify their separate classi- 
fication. They are properly placed with the clinical forms of disease 
termed, for provisional purposes, scrofulosis of the skin. 

ExANTHEMATIC MILIARY TUBERCULOSIS OF THE SKIN may follow 

the exanthematous fevers in children. The lesions are multiple, indo- 
lent, dull brownish-red tubercles, acuminate, situated in or near the 
cutaneous follicles and suggesting the lesions of acne papulosa. When 
in process of degeneration they form rounded, circular, or polygonal, 
sharply cut ulcers having a violaceous border, an irregular, granular 
floor, and a scanty sero-purulent discharge. Miliary nodules are to be 
seen both on the floor of the ulcerative surface and in the periphery 
of the lesion. They contain tubercle-bacilli. 

This disorder occurs, as a rule, in those exhibiting other and unmis- 
takable symptoms of tuberculosis. If the lesions be solely cutaneous, 
healing may result. 

4. Scrofuloderma. 

(Lat. scrofa, a sow.) 

The term Scrofula, or Struma, has been long and loosely applied in 
general medicine for the purpose of designating a number of diseases 
the real significance of which was unknown, their points of resemblance 
being greatly outnumbered by their specific differences. The researches 
of the last twenty years have been steadily and continuously restricting 
this list in almost every department of medicine. Many of the dis- 
orders once supposed to be scrofulous are now known to be syphilitic. 
In orthopaedic surgery a number of joint-affections once believed to be 
incontestably of strumous origin are known to be producible by 
traumatism exclusively. And in dermatology no less a broad advance 
has been made since the day when eczema, psoriasis, and acne were 
described as evidences of scrofula. 

The term scrofuloderm in these pages is strictly limited to those cuta- 
neous changes which occur in distinctly scrofulous subjects, and which are 
the result of tuberculous infection at one point or another of the body. 
By the term scrofula Billroth recognized a condition in which there 
occurs at any point in the body where irritation has been induced an 
indolent inflammation which persists after such irritation has ceased, 
which frequently terminates in suppuration and caseation, and which 
subsequently rarely pursues a hyperplastic career. If with this be con- 
joined inflammation and caseous infiltration of the lymphatic ganglia, 
or of the subcutaneous connective tissue ; amyloid degeneration of one 
or several of the viscera ; tumefaction of the belly ; chronic keratitis, 



TUBERCULOSIS CUTIS. 585 

ophthalmia, otorrhoea, or coryza ; a chronic arthritis (white swelling) ; 
a pasty, dirty-colored, and thick, or delicate and transparent skin 
exhibiting cicatrices of old abscesses or ulcers, and a voluminous nose 
overlooking thick everted lips, the general picture of the scrofulous 
patient may be considered complete. The recognition by Robert Koch 
of the etiological importance of the bacillus tuberculosis in tuberculous 
disease, and the demonstration of the presence of these micro-organisms 
in a number of lesions heretofore regarded as " scrofulous," have estab- 
lished their scientific position beyond controversy. The word " scrofu- 
loderma " should be hereafter limited in its application to lesions of the 
skin and subcutaneous tissue occurring in the subjects of tuberculosis, 
and due to the presence in such lesions either of tubercle-bacilli or of 
their toxins, or due to a cachexia induced by tuberculous infection of 
some other body-organ. With the advance of knowledge on this sub- 
ject the fact has been recognized that the toxins of tuberculosis may be 
responsible for a series of lesions and symptoms in which tubercle- 
bacilli cannot be demonstrated. In this way has been established a 
class of disorders to which Johnston has given the appropriate title 
of the " Paratuberculoses," and in which he has inscribed the scrofu- 
lodermata. 

The scrofulodermata are characterized by the occurrence of path- 
ological processes in the skin, lymph-glands, or periglandular tissues, 
which betray evidence of the scrofulous process. They usually begin 
as firm, well-defined subcutaneous nodules, similar in type to the syph- 
ilitic gumma, which gradually enlarge, become attached to the skin, 
subsequently degenerate, exhibit characteristic ulcers, and usually ter- 
minate by no less characteristic cicatrices ("Gommes Scrofuleuses," 
"Gommes Scrofulo-tuberculeuses," " Scrofuloma," Cold Abscess of 
the Skin). Pathologically they are all pyodermias, the product of 
acute inflammatory processes, and not of the type of the granuloma. 

The typical scrofuloderm is encountered about the face and neck, 
where the lymphatic glands have long been tumid and are either dense 
or doughy to the touch. This condition is usually reached very slowly; 
often months and years are required for its production. The glands 
may be as small as almonds or as large as the closed fist. Gradually a 
scrofulous dermatitis ensues in the skin which is superimposed. It 
becomes purplish and thinned and finally yields, giving exit to a sero- 
purulent fluid mingled with caseous matter and blood. The pus- 
corpuscles of this fluid examined under the microscope are seen to be 
poor iii protoplasm. Fistulous tracts and sinuses result, which under- 
mine and perforate the skin, resulting in the production of a chronic 
discharge and characteristic ulcers. The latter are far more remark- 
able for their borders and bases than for their floors. They are usually 
linear, occasionally elongated and oval, almost never circular. As a 
result, their uneven floors, covered with pallid granulations and a 
watery pus, are often hidden beneath their inverted, tumid, and un- 
colored edges ; or the latter may be thinned, stretched over a fistulous 
pocket, and reddish or purplish in color. Their bases are usually 
deeply attached to the subcutaneous tissue, and are firm or soft, never 
densely indurated. The resulting crusts are thin, tenacious, reddish 



586 NEW-GMOWTHS. 

or brownish, and, like the ulcer, often linear, rarely bulky, never 
rupioid. The resulting cicatrices are corded, depressed in irregular 
lines or bands, and often alternate with equally irregular nodules 
(scrofulous gummata) where the degenerative process either has been 
arrested or is still in activity. 

Rarely, enormous ulcers originate in the manner described above, 
which dissect out vast areas of subcutaneous and intramuscular tissue 
in the neck and even the extremities, in the course of which cartilage, 
bone, and periosteum are melted away. Usually but a few of these 
points of degeneration, from two to six, are exhibited in one patient. 

Another type of scrofulous gumma of the skin begins as a subcu- 
taneous nodule on the back or over the extremities of scrofulous children, 
the career of which is practically that outlined above. It differs chiefly 
from the lesion more or less directly connected with the lymphatic 
glands, by reason of its relation with lymphatic vessels distributed to 
a deeper and possibly distant tuberculous focus. 

According to Unna, there is a "dry" form which originates in the 
action of tuberculous toxin in the granuloma; and a "wet" form, the 
product of reaction of the nutrient channels and the resulting oedema. 
Tubercle-bacilli have been recognized in a few cases only, but their 
toxins have given rise to the pathological changes. 

Tuberculous Dactylitis, observed generally in children, is char- 
acterized by bulbous extremities of the fingers and toes, the skin cov- 
ering the same being at times the seat of infiltration and thickening. 
White * believes this process to be more common than that occurring 
in dactylitis syphilitica. 

Suppurative Tubercular Lymph angiectasis (Hallopeau and 
Goupil) is a condition in which scrofulo-tuberculous gummata, in 
small-nut- to egg-sized tumors, form along the lymph- vessels, of the 
lower extremity particularly. When such a tumor breaks down it 
furnishes the typical picture of the scrofulous ulcer, with its cheesy and 
watery pus, its thin edge, and its indolent career. In these rare cases 
bacilli have been recognized in the secretion. 

Tuberculosis Cutis Serpiginosa Ulcerativa is a term relating 
to a rare group of lesions in which brownish-red nodules, pea- to bean- 
sized, degenerate in the course of weeks or months until there results 
a centrifugally spreading, ovoid or roundish, even horseshoe-shaped 
ulcer, grayish yellow in hue and overspread with smaller cicatrices. 
Instead of nodules, the first lesions may be circumscribed areas of 
infiltration. The involved surface may be extensive, even larger than 
the two palms, and may coexist with secondary foci of involvement. 
Visceral and pulmonary tuberculosis may result. The resemblance of 
the large spreading patches to a serpiginous syphiloderm is striking. 

Lymphangitis Tuberculosa Cutanea (Besnier, Lejars).— The 
lymphatic vessels of the skin may be either primarily or secondarily 

1 Loc. cit. 



TUBERCULOSIS CUTIS. 587 

invaded with tubercle-bacilli, and in either event linear lesions form 
corresponding to the lymphatic trunks, or there develop tuberculous 
nodules or warts, dermic or subcutaneous in situation, which event- 
ually ulcerate and discharge pus, blood, or lymph. At times a reticular 
network results, with fistulous sinuses. Several of the lymphangiectases 
have been demonstrated to be tuberculous in character. 

Etiology of Tuberculosis Cutis. — Accidental inoculation of tuber- 
culosis may occur at all ages and in all sexes, the infective material 
gaining access to the economy in the large number of instances by the 
medium of the lymphatics. There is, however, ampler opportunity for 
such transmission among the members of any family in which pulmo- 
nary tuberculosis exists ; hence the widespread belief in the heredity 
of the disease. Attention has, however, been already directed in these 
pages to the striking fact that children are rarely born into the world 
tuberculous ; and to the possibility that all cases of reputed inherited 
tuberculosis were acquired by direct infection. 

Given, however, an infective micro-organism, the soil upon which 
it may flourish most favorably is of paramount interest in an etiological 
view. The young, the delicate, the cachectic furnish such a culture- 
field. With these must be included, as favoring such accidents, the 
mode of life of the very poor, the filthy, and the degraded. Thus, 
lupus vulgaris is originally developed in the majority of all cases 
during the first decade, between the third and sixth years of life ; 
rarely after the thirtieth year, for the reasons above given. The sig- 
nificant fact in this connection is that at this period of life the child 
often deprived of the constant care of the mother by the demands 
made by a still younger infant, untaught in the simplest rules of clean- 
liness, picking and scratching the face after miscellaneous contacts of 
the fingers with all sorts of material, is exceedinorlv liable to inoculate 
the skin of the face with tuberculous virus, if there be victims of such 
disease occupying the same apartment or house. It is significantly first 
upon the face in these early years, and next over parts such as the 
extremities or the genital region, to which the exposed hands have been 
carried, that the early symptoms of lupus vulgaris are betrayed. 
Further, it is noteworthy that well-marked cases are more frequent 
among the poor, the filthy, and the degraded than among the comfort- 
' able and cleanly. The prevalence of the disease in public as con- 
trasted with private practice is conspicuous in all statistics. 

As throwing additional light upon the question of childhood-infection, 
it is to be noted that other forms of tuberculosis occur at any period 
of life and in both sexes, when the accident of infection operates. 
Besnier, for example, reports a case of lupus resulting from tuberculous 
/ infection in vaccination ; Fournier, an instance in which a young woman 
was infected during the piercing of the ear for the insertion of earrings; 
Jadassohn, a case in which the tuberculous virus was inserted by tattoo- 
ing ; and Strauss, the history of a student who was wounded by a rapier 
in a duel, and as a result developed lupus in the site of the wound. 
In verruca necrogenica and warty growths of the same nature it is 
contact with the bodies of the dead or with tuberculous matter in any 



588 NEW-GROWTHS. 

form that determines the result. The aged with tuberculous lesions 
upon the backs of the hands, middle-aged persons with other evidences 
of cutaneous affection, actually suffer from generalized tuberculosis as a 
result of the accident. 

What may be said of the causes of lupus vulgaris relates also to 
scrofuloderma, which, while occurring in both sexes and at all ages, is 
more frequent in early life because of the susceptibility of the tissues 
at those periods. The difference between the manifestations of scrofu- 
loderma and those of other clinical forms of tuberculosis depends in 
large part upon the attenuation of the virus, seeing that relatively 
fewer tubercle-bacilli are to be recognized in the characteristic lesions 
of scrofula ; and the results of inoculations of cultures as respects the 
lower animals are markedly different. 

The soil fittest for scrofulodermatous manifestation is that where 
well-known agents have been most efficiently at work. All causes 
which tend to impair the nutrition and vigor of the body are, to an 
extent at least, efficient in its development, including privation from 
sunlight, fresh air, wholesome food, exercise, and hygienic influences in 
general. It is common among prisoners, exiles, and, in this country, 
among negroes and those of mixed blood. Consanguineous marriages 
are said to result often in strumous offspring. Syphilis in the third 
and fourth generations is known to be pathologically distinct from all 
the manifestations of scrofula. In many cases scrofuloderma is the 
sequence of other depressing medical diseases and surgical accidents. 
In certain instances, especially where it is limited to the neck, and 
accompanied merely by a cervical or submaxillary adenopathy, scrofu- 
losis is consistent with full vigor and nutrition of the body and all other 
evidences of sound health. 

Pathology of Tuberculosis Cutis. — Lupus vulgaris, tuberculosis 
cutis verrucosa, and scrofuloderma, as well as tuberculosis cutis orifici- 
alis (the one form hitherto recognized as tuberculous) are due to infection 
with tubercle-bacilli, and are practically identical histologically with 
tuberculous lesions in other organs of the body. The discovery of 
bacilli in lupous tissue, first made by Koch, has since been verified by 
Doutrelepont, Weichselbaum, Meisels, Schuller, Lustig, and others. 
The striking resemblance first shown by Virchow between a caseous 
miliary tubercle and a lupous nodule had, even before Koch's discovery, 
pointed to an identity of origin. The result of inoculation of culture- 
fluids has given positive results. Lenz, Hiiter, Schuller, ourselves, and 
others have produced tuberculosis by introducing in rabbits granula- 
tions taken from lupous, scrofulous, and other infected patients. 

For a knowledge of the microscopic characters of cutaneous tuber- 
culosis we are largely indebted to the Germans, whose opportunities 
for the study of the disease are unequalled. Virchow, Auspitz, Billroth, 
Lang, Kaposi, Klebs, Stilling, and Thin have amply contributed to the 
subject. 

The essential lesion in all forms of cutaneous tuberculosis is the 
nodule of so-called granulation -tissue, containing small round cells 
deeply stained by coloring-agents ; large cells, epithelioid in type, which 






TUBERCULOSIS CUTIS. 



589 



contain one or more large clear nuclei ; and giant-cells having a homo- 
geneous centre and few or many large vesicular nuclei situated for the 
most part along the border of the cell. Around and between these 
cellular elements is woven a network of connective-tissue bundles. 
In its early stages the nodule is about the size of a millet-seed, is 
grayish or reddish yellow in color and translucent, is situated wholly 
within the corium, is well defined in outline, and is well supplied with 
vessels. After a shorter or longer period, depending upon the activity 
of the process, the nodule undergoes changes. Although there is 
marked proliferation of the endothelium of the vessels, no new vessels 

Fig. 69. 




Section of lupus of face. X 750 and reduced. (Delafield and Prudden.) 

are formed, the old ones become obliterated, and there results a necro- 
sis — known as a coagulation-necrosis, or cheesy degeneration — of both 
cells and intercellular substance. In this condition the protoplasm is 
seen as a granular or amorphous mass, while the nuclei stain but feebly, 
if at all. Extension of the disease from the primary nodule may occur 
in the form of other circumscribed nodules, or as a diffuse infiltration 
of the tissues with the cell-forms above described, the small round cells 
being greatly in excess of the others. 

The process begins in the corium and extends to the epidermis and 
to the subcutaneous tissues, these adjacent structures being variously 
affected in the different forms of cutaneous tuberculosis. The epidermis 



590 NEW-GROWTHS. 

may be hypertrophied, exfoliating, or broken through by the tubercular 
infiltration, producing a typical ulcer. The nodules may soften and 
break down into a semifluid mass, and suppuration — always the result 
of secondary infection — frequently occurs. 

Tubercle-bacilli have been recognized in all parts of the nodule, both 
within and without the cells, but are usually most readily found in the 
giant-cells and in the outer portion of the nodule. Since giant-cells 
and nodules of granulation-tissue are found also in other than tuber- 
culous processes, the only pathogenic feature of the tubercle-structure 
is the presence of the tubercle-bacillus, though the coexistence of a large 
number of giant-cells and nodules or groups of epithelial cells leaves 
little doubt as to the diagnosis. 

In Lupus Vulgaris are found the characteristics of the chronic 
and slowly developing forms of tuberculosis. Giant-cells are numer- 
ous, the infiltration of round cells is marked, but epithelioid cells are 
present in comparatively small numbers, while the bacilli are very 
scarce ; many sections of tissue may be examined before finding a single 
bacillus. In lupus, more than in other forms of cutaneous tuberculosis, 
the proliferation of cells leads to a constructive or regenerative proc- 
ess as a result of which the lupus-nodule may be replaced by scar-tis- 
sue, or there may be an excessive formation of new connective tissue, 
producing the various degrees of elephantiasis so often seen in lupus. 
This intermingling of new tubercular foci of infiltration with hyper- 
plasia of connective tissue is what produces the many clinical forms 
of the disease. When the process is extending, the new growth, 
spreading along the vascular elements of the derma, involves finally the 
rete and the panniculus adiposus. The nest-like agglomerations disap- 
pear; there is in their stead an irregularly diffuse infiltration, producing 
subsequently hypertrophic, atrophic, desquamative, suppurative, or 
ulcerative sequels. Finally, the glands of the skin may become 
involved, the hairs falling from their follicles, the sebaceous glands 
either becoming obliterated or having their acini stuffed with epi- 
dermal masses which distend them in milium-like bodies grouped about 
a cicatricial pedicle. 

The epithelium is secondarily involved in lupus and may be desqua- 
mating, atrophied, or ulcerated. Not infrequently there is marked 
proliferation of the epithelial cells with down-growth of the inter- 
papillary processes. True epithelioma may thus result, in which event 
its course is usually rapid and destructive. There may be also a pro- 
liferation of the glandular elements of the skin. Leloir describes, as 
of rare occurrence, a colloid and a mucoid degeneration of the lupous 
tissue. 

In the Verrucous forms of cutaneous tuberculosis the tuberculous 
process proper usually is situated chiefly in the upper part of the 
corium, and there is more or less hypertrophy of the papillae and of 
the epidermal layers. In the well-marked cases of anatomical tubercle 
described by Biehl and Paltauf the horny layer is greatly thickened 
and shows cells in which the nuclei stain more or less, while between 
the layers of the cells are seen granular masses and the dried products 
of exudation. In places the horny layer dips down to fill the inter- 



TUBERCULOSIS CUTIS. 591 

papillary spaces. The papillae may be greatly hypertrophied and 
between them the rete may send projections deeply into the corium, in 
which occasionally are seen crypts filled with horny masses of epithe- 
lium. Secondary inflammatory changes and pus-infection may occur 
as in lupus. 

Between typical Verruca Necrogenica and the ordinary type of 
lupus vulgaris transitional forms frequently are seen which make it 
impossible to draw a line sharply dividing these forms of cutaneous 
tuberculosis. In verruca necrogenica a history of direct infection is 
often obtainable and tubercle-bacilli are more numerous than in the 
lupous nodules, though much less abundant than in tuberculosis cutis 
orificialis. 

In Tuberculosis Cutis Orificialis, both in the number of bacilli 
present and in the type of lesion, there is an analogy with miliary tuber- 
cle of other organs. Large numbers of typical, circumscribed nodules 
are found deep in the corium ; bacilli are numerous and easily demon- 
strated ; the degenerative processes go on rapidly, the tubercles break- 
ing down and coalescing to form masses of softened necrotic tissue 
which soon break through the epidermis to form an ulcer. About 
the borders of such necrotic areas new nodules are constantly form- 
ing, and the whole process is rapid, as in acute tuberculosis of other 
tissues. 

The Scrofulodermata originate in the subcutaneous tissues and 
I involve the skin secondarily. The lymphatic glands or the tissues 
' about the glands or lymphatic vessels become the seat of the tuber- 
culous process, which runs a subacute course. The glands or peri- 
; glandular structures finally break down into softened necrotic masses. 
Such areas of necrosis may remain indolent and superficial, or, in 
case a gland is involved, may be deep and extend by burrowing 
prolongations even to the bone. Sooner or later the skin over these 
I softened masses becomes involved in a subacute inflammatory process 
! and gives way, producing the typical ulcer with soft, ragged, and 
often extensively undermined edges. Experimental inoculations and 
the presence of tubercle-bacilli have demonstrated these subcutaneous 
processes to be tuberculous. The number of bacilli present varies 
greatly, being much larger than in lupus, but much smaller than in the 
; orificial forms of cutaneous tuberculosis. The relationship of the 
scrofulodermata to lupus is occasionally shown by the formation of 
typical lupous nodules near the border of these scrofulous ulcers, the 
result no doubt of inoculation of the skin with the discharge from the 
ulcer. 

Diagnosis of Tuberculosis Cutis. — Epithelioma, though rarely 
j resembling lupus vulgaris, is more often designated by that than by 
any other false title. Great confusion has arisen from the looseness 
with which several authors have furnished illustrations of "lupus 
jexedens," which were really pictures of cancer. But the latter is 
rarely a disease of early life, and when of early occurrence may not 
persist to adult years ; the reverse of which is true in the majority of 
all cases of lupus. The nodules of lupus are absent in epithelioma, 



592 NEW-GROWTHS. 

and the evolution of the disease slower, less painful, and, in its earlier 
periods certainly, of deeper situation. The ulcer of epithelioma is 
more often defined and single; its edges whitish, indurated, and 
everted ; its floor uneven and glazed ; its secretion scanty and occasion- 
ally fetid ; its base a mass of indurated tissue. Lupous ulcers are often 
ill defined and multiple ; their edges soft and inconspicuous, neither 
everted nor undermined ; their floors granulating and flattened ; their 
secretion relatively profuse and generally odorless ; their bases soft and 
pliable, though occasionally indurated. 

Tubercular, serpiginous, and ulcerative lesions of syphilis often re- 
semble certain forms of lupus. In any doubtful case a history of in- 
fection, of other types of cutaneous disease, of mucous patches, of 
adenopathy, of abortions in women, etc., should aid in the recognition 
of syphilis. The suspected lesions should be examined carefully for 
the purpose of distinguishing characteristic lupous nodules in the patch 
itself or in the periphery of any exfoliating area. In the case of an 
adult a history of long-existing lupus may often be obtained ; and it is 
worthy of note that syphilis with exceeding rarity displays for long 
periods of time a single exanthematous lesion or aggregation of such 
lesions exclusively in one part of the body. Lupous ulcers, often 
multiple and isolated, insensitive, Well- or ill-determined in outline 
(never reniform or horseshoe-shaped), with supple, low edges, and red- 
dish, smooth, hemorrhagic granulating floor, covered with crusts like 
soiled parchment of uniform thickness, do not resemble those of syph- 
ilis. The latter are often painful, single, circular, and clean cut in 
contour, with firm, raised, infiltrated margins, and with offensive green- 
ish and blackish crusts, resembling oyster-shells. The cicatrices of 
syphilis are elegant, smooth, delicate, superficial, circular, and, after 
pigmentation has disappeared, dead white in color ; those of lupus 
are irregular, indurated, deforming, yellowish white and reddish yellow. 
Acquired syphilis is a disease of adult life ; lupus commonly begins in 
childhood. 

The disks of psoriasis are distinguished from flat exfoliating patches 
of lupus vulgaris by the relatively large number of the former, by the 
nacreous lustre of the scales, the reddish hemorrhagic surface beneath, 
and the sites of election of the disks, usually on the extensor faces of 
the limbs. 

Lupus erythematosus is even more readily distinguished by its char- 
acteristics ; including the absence of nodules, ulcers, and crusts, the 
superficial character of the morbid process, the scaliness, and occasional 
symmetry of the patches. An intermediate form between lupus ery- 
thematosus and lupus vulgaris has been described, but most cases so 
classed probably belong to the type called by Leloir " erythematoid 
lupus vulgaris," in which nodules are temporarily absent. In all such 
cases typical nodules of lupus vulgaris develop sooner or later and 
confirm ^ the diagnosis. The two diseases, unfortunately somewhat 
similar in name, are distinct in character. The so-called intermediate 
forms may be instances of flat and scaly epitheliomatous infiltration 
going on to ulceration. 

In acne rosacea with a bulbous condition of the tip of the nose the 



TUBERCULOSIS CUTIS. 593 

redness is vivid ; and the telangiectasia complications, with the sebor- 
rhoeic flux, are conspicuous points of difference from lupus vulgaris. 
There is, further, no ulceration and little scarring, and the patients 
have usually suffered from the disease only after arriving at maturity. 
The mucous surfaces are also spared. 

The diagnosis of verrucous growths of tuberculous nature is to be 
made after an investigation of the history of each case, which often 
includes a record of contact with cadavers or persons capable of com- 
municating the disorder. The epitheliomatous warty growths on the 
dorsum of the hands of elderly persons are not to be confounded 
with tuberculous lesions. In the former there is commonly a history 
of longer existence of the wart, and no record of suspicious con- 
tacts ; while a careful search will usually determine epitheliomatous 

' metamorphoses over the cheeks or temples of the elderly man or woman 
with epitheliomatous warts on the hands. In the latter, too, the 

I facial lesions are usually multiple, fatty-looking scales, thicker in one 

1 part than another, resembling those of a severe seborrhoea, but which 

i are removed with difficulty, and which then leave a bleeding surface 

i beneath. 

In the orificial cases it must be remembered that tuberculosis of the 
viscera is a probable coincident disease. The microscope is usually 

■ needed for an exact diagnosis. 

The acneiform and sycosiform tuberculoses, necrotic granuloma, 
lupus pernio, folliclis, and other disorders of that group, many of them 
local evidences of infection of the system by the toxins of tubercle- 
bacilli, are distinguished by their superficial situation, their tendency 
to central necrosis, pitting and scarring, and by anomalous symptoms 
occurring where none such was to be expected. For example, a sycosis, 
apparently simple, leaves persistent disfiguring infiltrations, with scar- 
tissue and even ulcerative effects ; the acne which should resolve, 
exhibits deep, sunken, cicatriform pits, or papules which ulcerate ; the 
alopecia of the scalp, which at first seems to be of simple type, results 

; : in characteristic changes of the deep tissues. 

Treatment of Tuberculosis Cutis. — The internal treatment of 
tuberculosis cutis is practically that indicated by the condition of 
the patient ; inasmuch as no medicament is known to be capable, after 
. ingestion, of relieving the victim of his local ailments. Of the articles 
j in this category none will be more often indicated than cod-liver oil, the 
chalybeates, creosote, the bitters, the preparations of iodine, and possibly 
phosphorus. Iodoform and potassium iodide have been recommended 
by JSTeisser, who employs the former in pills, each containing \ grain 
(0.033). Guaiacol and creosote carbonate, either of them, in 5 grain 
(0.33) capsules, have been used with varying degrees of success. In 
London thyroid-extract has been given for cases of extensive tuber- 
\ cular disease of the skin with seeming benefit, though no complete 
cures are reported. The hypophosphites are useful in many cases. 
Arsenic and mercury are powerless to prevent extension of the disease. 
It is needless to add that a diet of the most generous character is to be 
supplied, and the rules of hygiene enforced. 

38 



594 NEW-GROWTHS. 

Patients of the tuberculous class manifest in the highest degree the 
beneficial effects of a change of residence and climate — to the seashore 
or mountains from the interior valleys or plateau-lands ; often the 
reverse for those who reside by the sea or in mountainous countries. It 
is the change which seems to produce the greatest benefit. An abun- 
dance of pure air and a life permitting out-of-door exercise are of 
the highest importance. The thermal and other springs of several 
countries furnish resorts where the benefit received is proportioned to 
the salubrity of the climate rather than to the special advantages of the 
waters furnished. Unfortunately, a large number of the patients 
affected with lupus and scrofuloderma are impoverished inmates of 
public charities or applicants to dispensaries, where these aids in the 
management of their ailments cannot be utilized. 

The local treatment of lupus vulgaris should have in view the 
removal of the morbid growth as painlessly and with as little resulting 
disfigurement as possible. These ends may be attained by surgical 
measures and by chemical and other applications. 

The surgical procedure most frequently employed is curetting with 
a sharp spoon. This, with all other bloody operations in lupus vul- 
garis, labors under the disadvantage of the possibility that tubercle- 
bacilli may be disseminated by the traumatism. Competent authors 
are arrayed on both sides of this question. Small lupoid patches cer- 
tainly may be spread after resorting to most of the surgical devices 
employed as remedial agents. The dermal curette is a sharp-edged 
spoon with or without a fenestrum in the bowl to permit the escape 
of debris. By it the lupous growth may be completely scraped away, 
and, if necessary, caustics subsequently applied. Fox and others sub- 
stitute for the sharp spoon the dental burr or dental excavator, though 
the change is not always for the better. Morris's double parallel 
screw-excavator is an improvement on the common burr. Often it is 
well to supplement the action of the spoon or excavator with the flat 
electrode treatment of Jackson. Gartner and Lustgarten originally 
used as an electrode a flat silver plate attached to the negative pole of 
the battery, the plate being set in a hard-rubber ring. A current of 
from five to eight milliamperes is employed. 

The ablation of the entire lupous patch by the modern methods of 
surgery, followed by skin-grafting with the Thiersch or Lang method, 
gives good results, though the lupous growths may return sooner or 
later in the new skin. The objections to this method are chiefly that 
it involves the production of a larger and more conspicuous scar, since, 
as a rule, more tissue is removed by the knife than by the curette and 
its allies. In the Lang l method the excision is made to include both 
the sound peripheral integument and half of the subcutaneous fat- 
cushion beneath, the skin-grafts employed later differing from the thin 
Thiersch sheets in that they include the derma with the epidermis as 
far as the panniculus adiposus. 

In the history of medicine it is seldom that a therapeutic measure 
has been followed by such satisfactory and brilliant results as those 
secured by the method of treatment of lupus vulgaris practised by 

x Der Lupus'nnd dessen operative Behandlung. Wien, 1898. 



TUBERCULOSIS CUTIS. 595 

Finsen, of Copenhagen (phototherapy 1 ). The morbid patch by this 
method is rendered anaemic by firm pressure with a planoconvex quartz 
lens, framed in a brass ring carrying two small tubes with four arms 
through which cold distilled water freely percolates, and through which 
is concentrated the light from an arc-lamp of between fifty and eighty 
amperes. The exposures are continued for about an hour daily, during 
which time a trained nurse in charge of the illumination presses the 
lens firmly over the spot selected for attack. When sunlight can be 
employed, its rays are substituted for those supplied by the electric 
lamp, the heat-rays being excluded and the violet and ultra-violet rays 
alone permitted to pass. The effects of solar light are, however, less 
decided and satisfactory than those secured by electric illumination, and 
as a consequence the out-of-door treatment of patients by sunlight is 
reserved in Copenhagen for those whose skins are unusually sensitive 
to the more vigorous and more brilliant light of operating-rooms. The 
exposure is rarely a source of pain save when the patch attacked is very 
near the eye, though often followed by redness, hyperemia, inflamma- 
tory reaction, and vesiculation. 

Patients relieved by this method of treatment and exhibited at the 
Dermatological Congress in Paris in 1900 furnished one of the most 
i convincing proofs of the essential value of the phototherapeutic method, 
| a fact fully corroborated by us during two several visits to the Finsen 
Institute. From a cosmetic point of view nothing can exceed the 
smoothness and comeliness of the faces subjected to this treatment. As 
with all other methods extensively pursued for the relief of hundreds of 
patients, there is a small proportion of failures, and a still smaller pro- 
portion of cases in which the electric rays seem to have had a prejudicial 
effect. No results however, at all comparable as to the number of 
patients relieved and as to the perfection of the relief obtained, have 
'been secured by other methods in the local management of lupus 
vulgaris. 

The objections to the method are : the length of time required for 
the treatment (though this is gradually shortening to six months and 
less); and the need of daily treatments — in some cases two daily — 
one in the morning and one also at night. The gratifying results 
obtained, however, much more than compensate for the time required 
to complete the work. 

The Roentgen rays have been employed for a similar purpose, and, 
it is claimed, with a similar effect by Albers-Schonberg, 2 Kummell, 3 
Pusey, 4 Himmel-Kasan, 5 and others. The relatively small number of 
cases thus far subjected to the treatment does not furnish a satisfactory 
basis for comparison with the Finsen method. 

Without question, next after the Finsen method and superior to it 
in the matter of the rapidity with which the lupous nodules may be 
made to disappear, is the thorn treatment employed by Unna. The 
thorns of the gooseberry bush are saturated in the German " liquor 

*Cf. "Die Finsenche Lichtherapie, Bang," Monatslfft. f. prakt. Derm., 1898, Bd. 
xxvii. ; Brit. Jour, of Derm., Sept., 1899. 

2 Deutsch. med. Woch., Oct. 13, 1898. 3 Arch. f. klin. Chir., Bd. lvii., Heft 3. 

4 Jour. Amer. Med. Assoc, Dec. 8, 1900. 5 Arch. f. Derm. u. Syph., Bd. 1., Heft 3. 



596 NEW-GROWTHS. 

stibii compositus," and one or more thrust firmly and deeply into each 
lupous nodule which it has been determined to attack. The base of 
each thorn is then cut off with a pair of fine scissors and the patch 
covered with a zinc oxide plaster. When the thorns are cast off a 
simple granulating ulcer is left which in favorable cases heals without 
delay. 

The obvious objection to each of the methods detailed above lies in 
the fact that an enormous proportion of lupus-patients have nasal and 
oral symptoms which cannot be reached either by the rays of solar or 
electric light or by Unna's thorns. The local treatment of these involved 
mucous membranes is a matter of great importance, and is described 
below. 

Hollander's hot-air treatment of lupus is accomplished by directing 
upon the lupoid tissue through a metal tube of slender diameter a 
stream of air at a temperature of about 300° C. The result is for the 
most part a destructive cauterization requiring complete anaesthesia. 
The resulting scars are formidable. 

The local treatment of lupus vulgaris by the aid of parasiticides is 
based upon the infectious character of the disease ; and in many cases 
is successful. White, 1 with a view to its parasitic action, applies to the 
lupous patches rags soaked in solutions of mercuric chloride, 1 to 2 
grains to the ounce (0.066-0.133 to 30.), and also applies ointments 
containing the same quantity of bichloride in the ounce of salve-basis. 
Favorable results have been also secured by freely painting lupous 
ulcers with a solution of corrosive sublimate in tincture of benzoin of 
the strength named. Salicylic acid, 2 to 4 per cent, solutions in castor- 
oil, and in ointments J to 1 drachm to the ounce (2.-4. to 30.) ; sul- 
phurous acid, or pyrogallol in ointments of 10 per cent, to 50 per cent, 
strength, spread on linen rags, covered with impermeable tissue, and 
followed by the use of mercurial plaster and iodoform, have all been 
successfully employed with the same object in view. 

Decidedly inferior to these are the following methods, the first 
named, most popular in Germany; the second, in France; the third, 
to-day practically obsolete, and probably not to be revived : 

The Paquelin knife is extensively used in Vienna. The finer 
blades, especially manufactured for the purpose, are thrust, at a red 
heat, again and again through the lupous tissue until it is destroyed in 
its depth. Over the whole the larger blade is firmly passed and pressed, 
the blackish coal resulting being the best subsequent dressing after the 
serous exudation ceases. Erasion is also followed by the use of the 
galvano- or thermo-cautery. 

Multiple linear scarification, a modification of the Dubini-Volkmann 
method, was once claimed to have changed the prognosis of the disease. 
It is doubtful whether anything is to be gained by either a preliminary 
freezing of the part or the use of cutting instruments with many blades. 
The incisions may be produced with a delicate bistoury held in the 
fingers like a pen. They should be in parallel lines, closely set 
together, and crossed ; should extend completely through the depth of 
the lupous growth ; and this is determinable after some practice by the 

1 Boston Med. and Surg. Jour., October 29, 1885. 






TUBERCULOSIS CUTIS. 597 

cessation of the creaking resistance which the blade fails to discover in 
normal tissue. Further, these incisions should extend laterally beyond 
the borders of the lupous patch into the sound peripheral zone. The 
bleeding is trifling and readily arrested by firmly pressing small pieces 
of fine sponge, lint, or absorbent cotton over the part. The edges 
of the incision unite either by granulation or by first intention ; and in 
both cases seem to serve as starting-points of the reparative process, 
the material for which, as already pointed out, seems to be supplied 
from the lupous nests themselves. Subsequent operations, when needed, 
require a previous freezing of the affected surface. In France and in 
some portions of the British Empire this method is still popular. 

Treatment by chemical cauterization alone is obsolete. The various 
acids and alkalies, particularly potassium hydroxide and lactic acid. 
Cosine's paste, silver nitrate, arsenical, mercurial, and zinc compounds, 
and sodium ethylate have all been employed thus, and in suitably 
selected cases have been in the past productive of fairly satisfactory 
results. 

With or without surgical interference, local applications may be 
employed, such as oily and fatty substances for the softening of crusts ; 
stimulating dressings of tar, iodated glycerin, thymol, guaiacol (Funk), 
ichthyol, carbolized glycerin, iodized phenol, fluorine (Phillipson), 
naphtol, chrysarobin, and iodoform; as also the carbolated unguents 
appropriate for the reparative phases of the ulcer left after the destruc- 
tion of the lupous growth. 

Unna advocates the topical application of 2 parts of beech-tar 
creosote to 1 part of salicylic acid, the latter for its marked effect 
upon lupous tissue, and the former for what is supposed to be its 
anodyne effect in obtunding the pain produced by the action of the 
acid on the surface. That this explanation of the effect of the com- 
bination is not wholly correct is shown by the well-known fact that 
creosote alone is capable of producing a curative effect upon lupous 
tissue. In a former edition of this work, issued before the date of 
Unna's experiments, creosote was set down as the dernier ressort of the 
physician in the topical management of lupus vulgaris. It can be 
used with the greatest advantage in severe cases not only by being 
brushed freely over the part, but also in the combinations suggested by 
Unna. It will be found that when employed alone it is far from hav- 
ing at first the local effect of a " morphine of the skin," being produc- 
tive, where no cocaine has been previously employed, of exquisite pain, 
which, however, is usually short lived. It should be applied only with 
the greatest caution by the practitioner's own hands, its effects watched 
and, if need be, counteracted, as in the local employment of potassium 
hydroxide. Trikresol operates in a similar manner. 

The application of fuchsin in 1 or 2 per cent, alcoholic solutions 
painted over the part, which has been previously scarified, is advocated 
by Fox and others. We have employed pyoktanin-blue in some cases 
with satisfactory results. 

In some of the German hospitals the new tuberculin-R, Koch's 
lymph, is injected, and, it is claimed, with a larger success than follows 
the older methods. It has not been unattended with danger, and fatal 



598 NEW-GROWTHS. 

results have in a few instances been recorded after its injection. In 
other cases general tuberculosis has been induced ; while in yet others 
the degree of improvement following its employment has been inferior 
to that more readily reached by other therapeutic measures. The dose 
is -g-J-g- to 1 milligramme, the strength being very gradually increased 
from the smaller to the largest amount named. 

The injection of calomel into the lupous patch has been followed by 
good results in the hands of Da Costa, Brouse, and Tschlenow. 

The treatment of verruca necrogenica and other verrucous tubercu- 
loses of the skin is practically that of lupus vulgaris. The curette 
may be followed by one of the caustics advocated above, preferably by 
pyrogallol, or a combination of salicylic acid and creosote. As a rule, 
mercurial lotions and salves are not well adapted to penetration of the 
warty or corneous envelope of the growth. 

The orificial lesions of tuberculosis cutis may, however, be well 
treated by these lotions, especially one in which \ to 2 per cent, of 
mercuric chloride is dissolved in compound tincture of benzoin or tolu. 

Veiel applies in all the cutaneous tuberculoses pyrogallol-vaselin in 
the strength of 10 per cent., spread upon lint for three or four days. 
One part to twenty of salicylic acid may often be advantageously 
added. 

The local lesions of scrofuloderma may require the use of hot borated 
lotions applied temporarily, or kept permanently in contact on com- 
presses covered by impermeable tissue. The results of surgical abla- 
tion of enlarged lymphatic glands, broken down or threatening scrofu- 
lous "gummata," a'nd the complete disinfection and aseptic treatment 
to the point of cicatrization of the resulting wounds, furnish proofs of 
the progress of modern surgery. 

In the local management of lichen scrofulosorum Hebra recommends 
the topical use of cod-liver oil smeared over the lesions, with woollen 
garments worn outside. At present medicated pastes are preferable. 
The local treatment of dermatoses of the scrofulous is, in fact, that 
indicated in each separate case. 

The Prognosis of tuberculosis of the skin in all its manifestations 
is in the highest degree variable. Many patients affected with lupus 
vulgaris, even after the production of the severest grade of deformity, 
recover and without further local manifestations gain a degree of facial 
comeliness that is marvellous. The scrofulodermata in the same way 
are remarkably improved, in the majority of all cases, by skilful medical 
and surgical management. In other cases systemic tuberculosis develops 
after even a single tuberculous infection, and grave results may occur 
either early in life or after years of tuberculous involvement of the skin 
and other organs. Other things equal, the prognosis in tuberculosis 
of the skin, as compared with that of other organs, is relatively favor- 
able, due to the sparsity of tubercle-bacilli in most cutaneous lesions, 
the skin being exposed too largely to external influences to form a 
good field for development of new colonies of bacilli. Any form of 
tuberculosis of the skin, however, may result in systemic infection 
and death. 



DERMATOSES OF SCROFULOUS SUBJECTS. 599 

THE DERMATOSES OF SCROFULOUS SUBJECTS. 

(Paratuberculoses, Johnston.) 

In this connection it is desirable to consider a group of cutaneous 
disorders which, while recognized as of occurrence among the scrofu- 
lous, exhibit lesions which, at the present time, have very rarely been 
determined to be sites of bacilli. They are supposed to be due to the 
presence of toxins, the latter, possibly in many cases, originating in a 
tuberculous focus in some organ of the body. Certain members of this 
group have been actually begotten by tuberculous injection. 

The evidence, as regards some of these forms, which may be consid- 
ered, perhaps, as pseudo-tuberculoses, or paratuberculoses, is instructive. 
The results of inoculation of tuberculous material in different lower 
animals seem to establish the fact that tuberculosis cutis, lupus vulgaris, 
and scrofuloderma differ widely in the number of bacilli that can be 
recognized in their respective lesions. It is, hence, argued that with 
even fewer micro-organisms present there may exist types of tubercu- 
losis still further removed from those here classified. 

In yet other cases the demonstration has been made that the toxins 
derived from any tuberculous focus in the human body may beget a 
cutaneous affection uninvolved by tubercle-bacilli serious or short lived, 
wholly or in part dependent upon the morbid state of the system. 

[A] Lichen Scrofulosorum. 

(Acne Cachecticorum, Acne Scroeulosorum. Ft., Folliculites 

des scrofuleux.) 

This eruption, first described by Hebra, 1 is characterized by its 
chronicity, and the occurrence chiefly upon the trunk, back, belly, and 
thighs, of millet-seed- to pinhead-sized, firm, flat, light- to livid-red, 
and grouped papules. These are occasionally surmounted at the apex 
by a minute scale, rarely by an equally small pustule. The lesions are 
at the onset isolated ; later they tend to arrange themselves in coin- 
sized patches ; when evolution is accomplished they are closely set 
together, the surface of the skin being then of a dirty reddish -brown 
color, and covered with thin scales, w T hich are readily detached. Often 
a crescentic outline can be determined in a group of aggregated 
lesions. 

The course of the eruption is slow ; often the cutaneous symptoms 
persist for months without apparent change, awakening little or no 
pruritus, and are followed by involution, accompanied by slight des- 
quamation and no cicatrices. There may be recurrence. 

In 99 per cent, of all cases observed in Austria there was concomi- 
tance of the general symptoms of struma named above (submaxillary, 
cervical, and axillary adenopathy, periostitis, ulcerative dermatitis, 
etc.), with frequent complications, such as eczema of the scrotum. 
The disease was encountered in young tuberculous subjects between the 
periods of infancy and puberty, never after the twentieth year. 

1 See his remarks before the German Surgical Society, Fourteenth Congress. 



600 NEW-GROWTHS. 

According to Kaposi, the disease consists in an exudative infiltration 
of the pilo-sebaceous follicles and the perifollicular tissue. Each 
papule represents, therefore, the orifice of a follicle, with an infiltrated 
perifollicular annex ; and its apical scale or pustule is formed of a 
mass of epithelial debris or an inflammatory exudate. Histologically, 
there is infiltration with lymphoid, epithelioid, and giant-cells, with a 
caseating area in the derma below the degenerating epidermis. The 
bacillus of tuberculosis has been very rarely discovered ; and the most 
of inoculation-experiments have been failures. 

The disease is readily diiferentiated from papular eczema by the 
absence of itching. From the miliary papular syphiloderm it differs in 
that the lesions of the latter, even though grouped, are always individ- 
ually distinct. The general symptoms, moreover, are strikingly differ- 
ent in the two diseases. Lichen scrofulosorum cannot be confounded 
with lichen planus or lichen ruber. Lichen pilaris, however, in a young 
and lymphatic patient might readily be mistaken for the disease in 
question. 

This scrofuloderm is rare outside of Austria. 

[B] Erythema Induratum Scrofulosorum. 

(Erytheme Indure des Scrofuleux, Bazin.) 

This disorder affects chiefly the lower extremities of young persons, 
especially girls, who have been accustomed to the erect posture for long 
periods of the day and who exhibit as well unmistakable symptoms of 
scrofula. The special circumstances in which this form of indurated 
erythema is produced are, primarily, a somewhat enfeebled constitu- 
tion, and, as a secondary or exciting cause, toil in the standing posture, 
as, for example, among laundresses and shop-girls. 

The symptoms are acutely developed or indolent, single or numer- 
ous, vividly red or purplish-hued, node-like patches on the front and 
calf of the legs or over the thighs, or even upon the upper extremities 
(Crocker). At times a single patch extends by multiplication or by 
spreading from an original site till a broadly infiltrated plaque is 
formed, somewhat suggestive of the lesions of erythema nodosum. 
The firm induration of the node is one of its striking features. The 
nodules may be either superficially or deeply situated ; painful and 
tender or quite insensitive, the last being the rule ; and may undergo 
a tedious involution, or degenerate and produce ill-conditioned ulcers, 
secreting a thin pus and at times communicating by a fistulous tract 
with underlying pus-cavities. Often it is difficult to distinguish clin- 
ically between these nodes and ulcers and those of syphilis ; the diag- 
nosis must then rest upon the history and concomitant lesions. There 
is, as a rule, absence of constitutional symptoms, and especially of fever, 
an important point in the distinction between this affection and erythema 
nodosum. Relapses are not infrequent. The disease is rare, occurring 
chiefly in public practice. 

The tuberculous nature of the lesions has not been determined defi- 
nitely. There is often- enlargement and in some instances suppuration 



DERMATOSES OF SCROFULOUS SUBJECTS. 601 

of the lymphatic glands of the subject of the malady. Johnston 1 and 
Audry 2 found in their histological examinations dilated vessels, the 
endothelium of the coiled portion of the sweat-glands swollen ; rarefied 
connective tissue with oedematous separation and disintegration of fibres ; 
and an irregular infiltration along the lines of the vessels with lympho- 
cytes and epithelioid cells. The hypoderm resembled a sponge. There 
were no tubercle-bacilli; no mast-cells; no giant-cells. 

Treatment is by administration of the remedies most efficiently 
employed in cachexia and struma, with a generous diet, a recumbent 
position of the lower extremities when these are the seat of the disease, 
and the ordinary management of chronic ulceration of the skin of the 
legs when such lesions are present. In a few cases potassium iodide 
has been given with advantage when there was no suspicion of syphilis. 

[C] Necrotic Granuloma. 

(Acnitis, Folliculitis, Acne Varioliformis, Acne Necrotica, 
Tuberculide, Spiradenitis, Hydros adenitis Suppurativa 
Destruens, Idrosadenitis, Disseminate Folliculitis, Gran- 
uloma Innominatum, Necrotizing Chilblain.) 

In this affection as yet but imperfectly differentiated from the 
several disorders classed as paratuberculides and described under dif- 
ferent titles, deeply seated, uncolored, painless, and rounded nodules 
form in the derma or hypoderm which persist for long periods and 
undergo a slow process of evolution. They at last become attached 
deeply to the surrounding and overlying skin, assume a more or less 
vivid, occasionally a brownish-red tint, and project slightly above the 
general level of the integument. Flattening and distinct depression 
of the apex occur, and later central necrosis. The split-pea-sized 
lesions are varioliform as to size and contour when seated on the hairy 
portions of the body ; on the extremities the type is that of the passive 
hyperemia of pernio. According to Johnston, the features of varioli- 
form acne are produced when the lesions are pierced by a pilary fila- 
ment, but those of spiradenitis when the coil-glands are involved. 
After separation of the dead central mass a minute pigmented pit is 
left. There is no tendency to coalescence. The resemblance of many 
of the lesions to a papular syphiloderm is striking. 

The disease occurs in the subjects of anaemia, struma, and cachexia, 
with a tuberculous family history and with coincident keratitis, oste- 
opathy, and menstrual derangements. 

No tubercle-bacilli have been discovered in the tissues examined. 
The morbid process is first distinctly recognized in the corium w T ith a 
cell-infiltration of perivascular site spreading thence to the coil- and 
sebo-pilary gland-systems. At first there is a moderate grade of 
oedema, which is followed by the development of giant- and epithelioid 
cells. After an arteritis obliterans central coagulation-necrosis follows. 
The explanation of the process suggested by Johnston is that a non- 

lu The Cutaneous Paratuberculoses," Phila. Med. Jour., February, 1899. The 
authors have made use of this essav in their discussion of this theme. 
2 Annal. de Derm, et de Syph., 1898, t. ix., p. 208. 



602 NEW-GROWTHS. 

microbic infection working from within outward first betrays its influ- 
ence by the vascular changes, and thence the toxin has probably been 
swept from a distinct focus through the blood- and lymph-streams to 
the point where its influence is first appreciated in the skin. 

[D] Folliclis. 

(FOLLICULITE DlSSEMINEE DES PARTIES GLABEES A TENDANCE 

Cicatricielle, Brocq.) 

This is one of the paratuberculoses of the skin, in reality a ne- 
crotic granuloma, described by Brocq, Barthelemy, Beauprez, Lefebvre, 
DuCastel, 1 and others, and by them assigned to a group of affec- 
tions which includes: acnitis, Darier's " tuberculides," lupus pernio, 
acne cachecticorum, erythema induratum, and other similar affec- 
tions. 

Folliclis is a rare dermatosis of strumous subjects first displayed in 
light-reddish, macules, which develop successively in crops and which 
progress to the formation of split-pea-sized, subepidermic and dermic 
nodules at the apex of which minute vesico-pustules may form and 
which furnish a thin secretion evidently exuded from the sebo-pilary 
and sudoriparous follicles. Later, in some cases, these lesions become 
umbilicated, deeply pigmented, and when involution is completed are 
followed by a minute cicatrix. They occur on the extremities, the 
abdomen, and on the hands, in the region last named displaying eryth- 
ematous plaques with adherent scales, the symptoms here being prac- 
tically those of lupus erythematosus. 

Histologically no tubercle-bacilli have been recognized and attempts 
at transmission to the lower animals have been largely failures. A 
small-cell infiltration has been recognized about the follicles invaded, 
followed by central necrosis and suppuration. 

[E] Lupus Pernio (Besnier). 

This is an affection of the face (ala? and bridge of nose, ears, malar 
eminences) and extremities, especially the dorsal surfaces of the hands, 
which is first displayed in circumscribed erythematous disks. These, 
at one or more points, may break down into superficial ulcerations 
where crusts form. There are accompanying oedema and formation of 
telangiectases. Upon the ears livid points are especially likely to be 
followed by tissue-necrosis in split-pea-sized areas, the disease here as 
elsewhere progressing with great indolence. The earlier symptoms are 
suggestive of the ordinary lesions of chilblain. There is no tendency 
to spontaneous involution. In some instances there is a striking resem- 
blance of the symptoms to those of Raynaud's disease. Synovitis with 
fungus has occurred in the joints. 

The affection develops in persons of delicate constitution, as also in 
those who are tuberculous and strumous. As yet no tubercle-bacilli 
have been recognized in the tissues examined. 

1 Cf. Annal. de Derm, et de Syph., 1887, p. 46 ; and 1888, pp. 814 and 1045. 



DERMATOSES OF SCMOFULOUS SUBJECTS. 603 

Erysipelas Perstans. — This affection resembles clinically toxic 
erysipelas, though the coccus of Fehleisen is not responsible for the 
symptoms. The affected tissue is cedematous, of a bluish-red, occa- 
sionally of a vividly red hue with few subjective sensations, rarely 
an accompanying fever, and but little tendency to spread extensively 
from a given point over the body-surface. It is chiefly remarkable for 
its tendency to persistence, to frequent recurrences from slight causes, 
and to the production of a brawny, firm, often beefy-red pachydermia, 
especially of the face, though also of the extremities. The affection 
occurs in persons suffering especially from purulent foci in the nose 
(rhinitis, polypus, lupus), in the mouth (caries of the teeth), in the lungs 
(tubercle), or in other organs where a purulent product is deposited. 

Histologically, like the other paratuberculoses, tubercle-bacilli are 
wanting; there are oedema of the derma and hypoderm, a serous exu- 
date, proliferation of connective-tissue corpuscles, and vascular dis- 
tention. 

[F] Pustular Scrofuloderma 

(Tuberculosis Suppurativa et Bullosa Acuta.) 

In this group of disorders the lesions occur as inflammatory papules 
or pustules of an evident follicular origin. In some cases vesicles and 
bullae have been commingled with the other lesions. The lesions may 
be small or large, few or numerous, limited to one or two well-defined 
patches or regions, or, as is more commonly the case, diffuse or irregu- 
larly grouped. In some of the milder circumscribed cases the mani- 
festations are limited to a few scattered or grouped papules and pus- 
tules situated about the hair-follicles. In other instances the lesions 
are larger, may coalesce, and be covered with more or less bulky crusts 
beneath which ulcers may form. As a rule, the course of the disease 
is slow and the lesions are indolent in type. Occasionally the symp- 
toms are more acute. In the majority of cases the folliculitis is evi- 
dently due to a local infection with pus-cocci in tissues having but 
feeble powers of resistance. In some instances, however, the toxin 
of a tuberculous focus may be responsible for the symptoms. 

[G] Acneiform Group of "Paratuberculoses." 

An acneiform group of paratuberculoses results from the common 
habit of picking and scratching the scalp, face, and beard. The finger- 
nails in these cases are probably the carriers of pyodermic infection in 
the skins of strumous and tuberculous subjects. The " lupoid sycosis" 
of certain writers refers to a class of cases which may be regarded as 
distinct from the simpler varieties of sycosis, since in the " lupoid " forms 
lesions persist for several years, and finally leave atrophic and scar- 
like or simply wasted lines, points, or areas in the region of the male 
beard. Some of the disorders of the scalp termed " epilating," " cica- 
tricial," " unnamed," " follicular and perifollicular," and " neurotic " 
alopecias, may be one day assigned to this class of affections. 

Acne Necrotica (Ulerythema Acneiforme). — Under the title 



604 NEW-GROWTHS. 

last named Unna 1 describes and figures a disease on the face of a young 
girl, beginning with the production of papules in the centre of the 
cheek, where finally developed comedone-like masses ; the lesions with- 
out suppuration eventually left reticulated and pitted scars perceptibly 
sunken and traversed by dull-white ledges between which comedones 
were visible. The lesions were also visible about the scalp, forehead, 
and ear. Anatomically it appeared that inflammatory symptoms re- 
sulted in a perifollicular cell-infiltration, with dilatation of lymph-spaces 
and consequent changes in the epithelium, as well as in the muscular, 
elastic, and other tissues. 

" Tuberculous Eczema " (Unna) is merely an exudative affection, 
which may be recognized in proximity to the scrofulodermata, a process 
awakened by the irritative effects of the latter ; or the disease occurs, 
as do other affections, in scrofulous patients. 

Melanoderma of the Scrofulous (Pigmentary Tuberculide). 
— In some of the subjects of scrofula and tuberculosis a hyperpigmen- 
tation of the skin has been produced strongly resembling the pigmen- 
tary syphilide. The coloration is in varying shades of brown, and forms 
a reticulated staining of the regions about the face and neck, though 
other parts may be involved. Between the pigmented spots lighter 
points and dots of a less deeply stained integument are commonly 
visible. The well-known influence of tuberculosis of the adrenals hi 
the production of pigment-changes in the skin lends color to the 
belief that some of these cases are due to the toxins of a tuberculosis 
of non-integumentary tissue. Similar pigment-changes in the skin 
have been determined to be the result of paludism, carcinoma, syphilis, 
and other disorders : and it is reasonable to conclude that the changes 
here set down in some instances at least are the product of tuberculous 
toxins. 

Lupus Erythematosus (consult the following chapter) is by some 
authors classed with the disorders grouped under the title of tubercu- 
losis cutis or as a paratuberculosis. The evidence that it is itself a 
cutaneous tuberculosis is wanting. That, however, it is in some cases 
a dermatosis of the scrofulous cannot be questioned. 

LUPUS ERYTHEMATOSUS. 

(Lat. lupus, a wolf.) 

(Lupus Sebaceus, Lupus Superficialis, " Scrofulous Ring- 
worm," Seborrhcea Congestiva, Lupus Erythematodes, 
Lupus Non-exedens, Ulerythema Centrifugum. Ft., 
scrofulide erythemateuse, erytheme centrifuge.) 

This disease was first described by Biett under the title Erytheme 
Centrifuge. Hebra, in 1845, described it among the seborrheas, as 
Seborrhoea Congestiva. Its present title was given by Cazenave in 
1850. 

Symptoms. — The disease is first exhibited in one or several rape- 
seed- to bean-sized, slightly elevated reddish macules which do not 

1 Internat. Atlas of Kare Skin-diseases, 1889, i. 



LUPUS ERYTHEMATOSUS. 605 

entirely fade under pressure and are covered with a grayish or yellow- 
ish and sometimes slightly greasy, adherent scale. 

In the ordinary Discoid form of the disease the primary lesion 
described above enlarges its periphery in the course of months or years 
by a slowly continuous development. It may thus gain the size of a 
small coin or a large saucer. The disks or patches are well denned 
in outline, of a color varying with the complexion of the patient and 
with the acuteness or type of the disease, from a rosy-pinkish to a deep- 
purplish hue. The shape is usually circular, oval, or in figures rep- 
resenting combinations of these outlines, but it may be irregular from 
the junction of two or more progressing patches. Its border is red, 

Fig. 70. 




Lupus erythematosus of the face. 

firm to the touch and distinctly elevated, and not infrequently exhibits 
comedones or light adherent scales. The centre is depressed, paler in 
color, and shows either adherent yellowish-gray scales or a glistening 
unbroken epidermis. Close examination will disclose in most cases 
dilated follicular openings w r hich may be plugged Avith dried sebaceous 
matter or horny epithelium. The scales vary in color, being at times 
of a clear white or whitish yellow, and again often from concurrence 
of comedones of a reddish or brownish tint. They are usually scanty 
and adherent, but may be abundant, and can occasionally be seen 
firmly fastened to the orifice of the excretory duct of a sebaceous gland 
by means of a horny projection from the under surface. In some cases 
the erythematous redness, in others the crusted surface of the disk, is 



606 NEW-GROWTHS. 

the most pronounced feature. In the latter there are seen at times 
patches exhibiting almost a pure type of seborrhcea faciei. 

The disease is seen most frequently on the nose and cheeks, over 
which it may spread symmetrically in a form that has been likened 
by Hebra to the open wings of a butterfly. It occurs also on other 
parts of the face, the ears, the scalp, the back of the hands and ex- 
ceptionally on other portions of the body. On the scalp the dilated 
follicles and comedones are especially pronounced, while the elevated 
border is rather less distinct than on the face. The alopecia which 
results is permanent. Rarely the mucous membrane may be involved, 
presenting reddened plaques with minute excoriations, or partially cov- 
ered with a whitish exudate or with punctate scars. 

As the borders advance the centre not infrequently undergoes invo- 
lution, and may show typical scars even while the outer rim is actively 
progressing. When the disease undergoes general involution both the 
centre and the border gradually become paler in color and less ele- 
vated. Some of the patches resolve without leaving a trace of their 
existence, but in most instances typical scars are left. These are in- 
delible and characteristic. They are generally uniform and superficial, 
can be pinched up readily between the thumb and finger, are of a dull- 
whitish tint, and rendered punctate in a peculiar manner, suggesting 
the action of the engraver's tool in what is known as the " stippling " 
process. They are never pigmented, puckered, radiate, stellate, corded, 
or deeply attached. 

The disease is remarkably chronic in its course, lasting in cases for 
a quarter of a century or even longer, and throughout not interfering 
with the general health. So-called " galloping cases," usually with 
marked visceral complications, are described by French writers. The 
disease varies in the subjective sensations it produces, being generally 
accompanied by no discomfort, though at times by some itching or 
burning. It is more common in women than in men, and is a disease 
of adult years, usually appearing first in the third or fourth decade. 
Kaposi reports a single case in a child three years of age. 

Though the disease usually progresses by a very slow extension of 
the border, it may, after remaining comparatively stationary for months 
or years, rapidly advance for a short period and then again remain sta- 
tionary. These periods of rapid progression usually follow or are 
accompanied by a peculiar type of acute dermatitis suggesting a mild 
form of erysipelas. 

Among the unusual features of the disease may be mentioned an 
acute form, named by the French Eeytheme Centrifuge, which has 
most of the characteristics described above, except that the symptoms 
are more acute and the vascular elements more marked. This condi- 
tion may disappear, leaving the skin entirely normal, or it may be fol- 
lowed by the more common type of the disorder. The reddened 
plaque has been by several authors likened to the lesions of exudative 
erythema, being hot to the touch, tender, raised, and manifestly cen- 
trifugal in its mode of extension. 

The Telangiectatic form is occasionally seen. Here points, spots, 
plaques, or large disks, on the surface, chiefly of the face, usually well 



LUPUS ERYTHEMATOSUS. 607 

defined, present a rosy-reddish, or deep-purplish color which disap- 
pears under pressure. When examined with care the color is seen to 
be due to dilatation of the cutaneous vessels. The surface may be 
either slightly cedematous, or infiltrated, and correspondingly elevated. 
There is an absence of scaling and of dilated follicles, but typical scars 
not infrequently follow the involution of this type of the disorder. 

Lupus Disseminatus. — The disease occasionally occurs in a dif- 
fuse form. As a rule, the lesions first appear on the face, but later 
they develop on any part of the body, and often large surfaces are 
involved. The lesions are small, varying in size from that of a pinhead 
to that of a bean, and though usually presenting characteristics similar 
to the beginning patches of the more common type, they may assume 
atypical forms resembling the lesions of erythema multiforme, urticaria, 
syphilis, acute psoriasis, or pityriasis rosea. At times the subjective 
sensations are severe (itching, burning, heat, etc.), and the patches may 
even be the seat of vesicles, pustules, or bulla?. This form of the dis- 
ease is accompanied in most instances by such systemic disturbances 
(arthritic, gastro-intestinal, and febrile) as occur in erythema multi- 
forme. In rare instances there are changes suggesting erysipelas, some- 
times accompanied by typhoid and other malignant symptoms. In 
some of these cases death has resulted. 

Lupus Pernio 1 is another unusual form in which the lesions are 
exhibited on the fingers and toes particularly, but also on other parts 
of the hands and feet and on the pinna of the ear, beginning as a more 
or less persistent erythema of the type of pernio (chilblain). Like the 
latter disease, this erythema may disappear and reappear with the 
seasons for several years, but eventually may persist and assume the 
discoid type. 

The Livedo Form. — A rare subvariety is recognized on the face, 
hands, and other regions where the symptoms present the character 
of local asphyxia. Here the influence of the trophic nerves, as in 
other conditions with similar symptoms, is distinct. The disease begins 
with the production of livid spots in the regions named, which persist 
for months or even years, and eventually degenerate at the centre, 
leaving a slough beneath which is an ulcer. In these cases, also, tuber- 
culous complications may occur in the joints. 

Etiology.— -Lupus erythematosus is described by some writers as a 
variety of lupus vulgaris, but the histopathology of the former disease, 
the absence of tubercle-bacilli, and the negative results of many inocu- 
lation-experiments seem sufficient to disprove such relationship. The 
transitional forms occasionally reported usually prove to be mild and 
unusual types of lupus vulgaris. 

Although lupus erythematosus has none of the essential character- 
istics of a local tuberculosis, it occurs not infrequently as a dermatosis 
of the tuberculous. Besnier was the first to call attention to the fact 
that lupus erythematosus is in many instances associated with general 
or local tuberculosis. Cases in which this association occurred have been 

1 Cf. contributions to this subject by one of us, Jour. Cutan. and Ven. Dis., 1884 ; 
and by Ohmann-Dumesnil, Ninth Internat, Medical Congress, 1887. 



608 NEW-GROWTHS. 

reported by a number of observers. Boeek x records forty-two cases of 
the common discoid type, in twenty-eight of which he found evidences 
of present or past tuberculosis. Roth 2 collected records of two hundred 
and fifty cases of lupus erythematosus, in one hundred and eighty-five 
of which evidence of local or general tuberculosis could be obtained. 
In such cases Boeck concludes that the toxins of the tubercle-bacillus 
act first upon the vasomotor centres of the skin and later upon that 
portion of skin which is the seat of the vasomotor disturbance. 

Tuberculosis should thus be counted as an important factor in the 
etiology of lupus erythematosus, but that it is the sole cause or even 
an essential factor has not been demonstrated. The disease is seen fre- 
quently in individuals in whom there is no history or other evidence of 
tuberculosis in any form. It occurs in conjunction with anaemia, 
chlorosis, and other disorders. In many patients careful investigation 
fails to discover any other evidence of ill health. By some writers the 
disease is considered a chronic inflammation due to a specific infection. 

The disease is more common in women than in men, two-thirds of 
the former to one of the latter, and usually appears first in the third 
decade of life, in this particular presenting a contrast with lupus 
vulgaris. It may, however, first develop in childhood, middle life, or 
old age. 

Lupus erythematosus may follow eczema seborrhoe'icum, acne, undue 
exposure to sunlight, variola, erysipelas, vesication with cantharides, 
or the traumatism of leech-bites. It may appear where the curette 
has been employed in a patient with a characteristic patch elsewhere 
on the face. It occasionally develops on portions of the face and hands 
that have been subject to recurrent attacks of pernio. 

Pathology. — Lupus erythematosus has been studied carefully by 
a number of observers, but unfortunately they do not agree either in 
their histological findings or in their conclusions based upon the 
latter. In general it may be said that the chief changes are found 
in the upper half or third of the corium in the form of a dense infil- 
tration of small round cells of embryonic type, a small proportion of 
which is probably the result of proliferation of the fixed cells of the 
part. The infiltration varies greatly in extent and in density in dif- 
ferent types of lesions, but is most pronounced along the course of the 
vessels. It is often found in slight degree in the deeper parts of the 
corium and subcutaneous tissue ; but it nowhere forms nodules as in 
lupus vulgaris ; there are no giant-cells ; and there is no degeneration 
of a mass of cells as in the latter disease. Individual cells here and 
there undergo a granular and fatty or colloid degeneration, disappear 
by absorption, and are replaced by new cells. The connective-tissue 
fibres are destroyed in the same way. Many of the vessels are seen 
to be greatly distended and choked with red blood-corpuscles, others 
show a proliferation of their walls and in some cases an obliterating 
endarteritis. Diifuse or localized hemorrhages are found in the upper 
part of the cutis. By some observers the vascular changes are con- 
sidered primary in the process. The sebaceous glands are at first 

1 Arch. f. Derm. u. Syph., 1898, Bd. xlii., S. 71. 

2 Ibid.,, 1900, Bd. li., S. 3. 



LUPUS ERYTHEMATOSUS. 609 

hypertrophied, affected with hypersecretion, and become filled with cells 
and abnormal sebaceous matter. Later both they and the ducts of the 
coil-glands may become infiltrated, undergo degeneration and dis- 
appear, leaving the peculiarly punctate form of scar characteristic of 
the disease. 

The epidermal layers are involved secondarily. They become 
atrophied, and the interpapillary depressions of the rete as well as the 
papillae are largely obliterated. 

Fordyce and Holder 1 investigated a number of cases of the discoid 
type and describe a peculiar blocking of the capillaries with blood-cells 
which they believe to be the primary change. They divide the factors 
making up the histopathological complex into the round-cell infiltra- 
tion, the peculiar degenerated condition of connective tissue, and the 
secondary atrophy. They find that the commonly described fatty and 
granular degeneration is not characteristic of the process, and recom- 
mend that for purposes of study tissue from lupus erythematosus areas 
be imbedded in paraffine and stained with acid orcein. 

Robinson, 2 after examining a number of cases and reviewing the 
published reports of others, states that the primary lesion, which 
may be seated in any part of the corium, is focal in character, and 
when fully developed constitutes a new-growth, which is reticular in 
structure and closely connected with the lymph-channels. He con- 
cludes that " lupus erythematosus is a chronic inflammatory disease of 
the cutis with special histological characters, as shown by the changes 
in the blood-vessels — new blood-vessels in the affected area, lymph- 
vessels and lymph-channels, and the new-formation of an adenoid-like 
tissue — by reticular tissue, by the presence of mononuclear and by the 
absence of polynuclear cells in the cell-infiltration; and that these 
changes must depend upon the presence of a poison generated in loco. 
In other words, lupus erythematosus is a local infective process — a 
granuloma." 

Diagnosis. — The facies of the patient with lupus erythematosus of 
that region is Usually so characteristic that the disease is there recog- 
nized with ease. When the hand and other portions of the body are 
involved the diagnosis is somewhat less readily established. In the 
hand the disease has a predilection for the dorsum, and invades the 
palm usually only by extension to it from behind. 

From lupus vulgaris erythematous lupus may be recognized by its 
occurrence originally at a later period of life ; by its greater tendency 
to symmetry; and by the absence of nodules, ulceration, and extension 
to the deeper portions of the skin or underlying structures. Cases 
undoubtedly occur in which the diagnosis is difficult, as in the type 
called by Leloir lupus vulgaris erythematoide. But as in all cases 
of lupus vulgaris typical nodules appear sooner or later, the diagnosis 
can eventually be established. 

In eczema there is usually some history of moisture ; in erythema- 
tous lupus, rarely. In eczema, also, the itching is a more persistent 
and distressing symptom ; but the acuteness of even chronic eczema, as 

1 N. Y. Med. Kecord, July 14, 1900. 

2 Trans. Amer. Derm. Assoc., 1898. 

39 



610 NEW-GROWTHS. 

compared with lupus erythematosus, will suffice to distinguish the two 
diseases. From eczema seborrhoeicum, however, the diagnosis may be 
difficult and may have to depend on a therapeutic test, the latter dis- 
ease disappearing under appropriate treatment. Psoriasis is rarely, if 
ever, limited to a single patch on the face ; it is also characterized by 
more lustrous and more readily exfoliating scales. Its patches are, 
furthermore, uniformly well covered with scales, and are of equal flat- 
ness in all parts, while those of lupus erythematosus are irregularly 
squamous, the scales being often clustered at the orifices of the ducts 
of the sebaceous glands, while the rim of the patch is elevated and the 
centre depressed. From pernio the diagnosis sometimes can be made 
only after determining whether the lesions disappear during the warm 
season, as in pernio ; or persist, as in lupus erythematosus. 

In acne rosacea there are marked telangiectases and papulo-pustules 
or nodules which are not found in erythematous lupus. In tinea cir- 
cinata there may be a clearing, but never a cicatriform centre of the 
circular disk. The circular serpiginous syphilodermata of the face 
occur usually with other manifestations of lues, are characterized by 
greater infiltration, a more rapidly progressing border formed by the 
coalescence of individual papules or tubercles, and in most cases the 
syphilitic lesions exhibit distinct signs of ulceration. The not infre- 
quent modification or masking of a patch of the disease by an acute or 
subacute dermatitis (often seborrheal in character) should be borne in 
mind. 

Treatment. — The internal treatment of this affection is not highly 
satisfactory ; often none is indicated or required. Of course, the general 
health of the individual should be carefully investigated, and all defects 
remedied if possible. The administration of potassium iodide, mercuric 
iodide, iodoform in 1 grain (0.06) doses (Whitehouse), starch iodide, 
arsenic, iodoform, ammonium carbonate, ichthyol, sodium salicylate, and 
many other remedies have been advocated by different writers. It is 
doubtful if these articles ever do good unless indicated by the patient's 
general condition, while they often do much harm. The last three 
remedies on the list given above are said by Fox, Unna, and others, to 
lessen the congestion of the face. When they do produce this effect it 
is possible advantage may be derived from their use. 

The local treatment of the patches of the disease is of importance, 
for though the number of cases amenable to treatment is decidedly in 
the minority, the fact that even a few improve or recover under 
treatment is sufficient reason for attempting to remove this unsightly 
disorder. The number of remedies recommended for local use in 
lupus erythematosus is enormous. White, 1 in reviewing the subject, 
has enumerated some fifty of those most promising, at the same time 
calling attention to the fact that lupus erythematosus is no exception 
to the rule that "the curability of a disease is in inverse ratio to 
the length of the list of the means recommended for its cure." He 
admits that our treatment of this disease is wholly empirical and not 
very hopeful. Unna 2 attempts a rational form of treatment based on 

1 Jour. Cutan. and Gen.-Urin. Dis., 1898, p. 457. 

2 Ibid., ,p. 465. 



LUPUS ERYTHEMATOSUS. 611 

his conception of the etiology and pathology of the disease and of the 
action of certain remedies. While his scheme is based largely on 
theories that are not yet capable of demonstration, the details of his 
treatment are of practical value. He calls attention in particular to the 
fact that while the epidermis is exceedingly dry and hyperkeratotic, the 
cutis is markedly cedematous and the seat of dilated lymph-spaces and 
channels, and emphasizes the dangers of stimulating a dry indolent 
process into an active dermatitis. 

For convenience, the remedies used may be divided into three 
classes : the soothing and astringent, the stimulating, and the destruc- 
tive. The choice of remedies will depend largely upon the type of 
the disease and on the character of the individual skin. In the acute, 
inflammatory, or vascular type soothing remedies alone should be used, 
and on a skin which reacts readily to stimulation stronger remedies 
are not allowable. Nor should it be forgotten that the indolent forms 
of the disease not infrequently under treatment become acutely in- 
flamed, and call for the temporary use of soothing measures. Inas- 
much as the affection is one the involution of which occasionally is ac- 
complished under the influence of mild topical applications, and is 
succeeded very rarely by grave sequels, the simpler measures should 
always be adopted first. In the way of soothing and astringent prep- 
arations, the lotions, powders, simple ointments, and pastes recom- 
mended for the treatment of acute eczema can be employed to advan- 
tage. The zinc oxide powders and lotions are especially to be com- 
mended, as are also the cold-cream salve, the Hebra, and the zinc oxide 
ointments. The paste containing equal parts of lanolin, vaselin, zinc 
oxide, and talcum makes an excellent base. Boeck's liniment (talci, 
amyli, aa sijss (10.); glycerin., 3j (30.); aq. plumbi, sv (160.); and 
Unna's " pulvis cuticolor " (zinc, oxid., boli rubrse, aa, 2 ; boli albse, 
magnes. carbonat., aa, 3 ; amyl. oryzoe, 10) are valuable preparations 
in acute and irritable stages of the disease. 

Frequently much can be accomplished through protection and com- 
pression of the surface by the application of collodion, the glvcogela- 
tins, or tragacanth-jelly. Unna recommends especially for irritable 
casee : 

R Ichthyol. (vel ichthyol. sulfon.), 3ss ; 2 

Collodii, 3v; 20 M. 

For more indolent cases : 

R Saponis virid., 3ss-ij ; 2-4 

Collodii, 3v; 20 M. 

To the latter may be added 1 or 2 parts of salicylic acid. 

Unna recommends also gelanthum as a substitute for collodion in the 
above formulae, for though it does not produce as much compression 
as the latter, it is more convenient in that it may be washed off at any 
moment with warm water. A favorite formula with him is potass. 
hydrat., 1 ; gelanthum, 1000. 

For the purpose of producing more or less stimulation of the sur- 
face there may be added to the lotions, ointments, and pastes suggested 



612 NEW-GROWTHS. 

above, from 2 to 20 per cent, of sulphur, or from 1 to 5 per cent, of 
salicylic acid, white precipitate, resorcin, ichthyol, or tar. The mild 
salicylated soap plasters or the plaster-mulls containing the above 
remedies in small amounts, or a reduced mercurial plaster may be 
used where a moderate amount of stimulation is desired. Excel- 
lent results follow the use of green soap applied as a plaster or in the 
form of tincture. It not only cleanses the patches of the scales, but 
also stimulates the surface, often to the extent of inducing a repara- 
tive process. The patch may be briskly rubbed either with soap or 
tincture of soap in combination with hot water, after which a simple 
ointment or one containing a small amount of sulphur or other of the 
remedies suggested above may be applied. When decided irritation 
of the parts is produced, the soap should be discontinued and the hot 
water and ointment be employed alone for a time. A decidedly bene- 
ficial effect is noted occasionally after the topical application, for 
twenty minutes at a time, of very hot water alone. After drying, the 
surface should be dusted with a powder or covered with a simple oint- 
ment or paste. 

The following is a gentle stimulant : 

R Zinci sulphat., J __ ^ 



Potassii sulphuret., [ *.«o**, aa l 

Spts. vin. rectif., f 3iij ; 12 

Aq. rosse, f ^iijss ; 105 
Sig. To be diluted as required for external use. 

The following is a formula for a stronger lotion : 

R Chrysarobin., Sijss; 10 

Acid, salicylici, ] s - _ -- o 

Calaminis pulv., j aa 3ss; aa Z 

JEtheris, f 3j ; 4 

Collodii flex., f3v; 20 

Sig. To be applied with a brush. 



M. 



M. 



The non-vascularized, indolent varieties of erythematous lupus are 
often treated with very satisfactory results by the topical application of 
a saturated solution of pyoktanin-blue. This method has the great 
disadvantage of producing a deep bluish stain of the face, but the dis- 
figurement is willingly tolerated for a brief period by patients who have 
long suffered from -the facial unsightliness of the disease itself. The 
solution is thickly painted daily over the entire portion affected ; and 
the application usually may be made by an unskilled hand. No pain 
is produced and no untoward effect of any kind has been noted. The 
applications have been repeated continuously for sixty days and more 
with excellent results. 

Enzymol painted over each patch several times in the day has been 
followed in some cases by marked improvement. 

Hans Hebra 1 applies several times daily alcohol on cotton pads. 

1 Wien. med. Woch., 1899, pp. 13-18. 



LUPUS ERYTHEMATOSUS. 613 

The evaporation of the spirit and abstraction of water produce the 
beneficial effect. 

Finsen's phototherapy, described under the treatment of lupus vul- 
garis, and the employment of the #-ray have been successful in a few 
cases. 

In exceedingly obstinate cases, those especially in which the elevated 
rim of the erythematous disk refuses to yield to the simple measures 
described, a solution of caustic potash in distilled water, 1 part to 2 or 
4, may be gently applied with a camel' s-hair brush, and the alkali 
immediately neutralized by the addition of dilute muriatic acid as soon 
as the desired effect is produced. That effect, it must be remembered, 
is superficial cauterization only. When the sero-sanguineous exudation 
and reactive effects disappear the rim is seen to be flattened and to have 
lost in part its violaceous blush. After such severe application, which 
should never be trusted to the hand of one unskilled in its use, an 
anodyne cerate containing morphine or opium should be spread over 
the part. 

In indolent patches where decided stimulation or even a very super-, 
ficial destruction of tissue is desired, mercurial plaster, the stronger 
salicylated soap-plasters, and plaster-mulls are to be recommended, or 
creosote, carbolic acid, thilanin, chrysarobin, pyrogallol, salicylic acid 
and pyrogallol (1 part of the first and 3 of the second to 40 parts of 
flexible collodion, Brocq), silver nitrate, lactic acid, or Fowler's solution 
may be used. Two drachms (8.) each of iodine and potassium iodide 
mixed with 4 drachms (16.) of glycerin ; or equal parts of chloral, 
tincture of iodine, and carbolic acid, are recommended highly. These 
stronger remedies, however, are to be used with great caution and only 
in indolent cases, and then only after milder measures have failed to 
produce good results. 

Where more extensive destruction of tissue is required caustics are 
applied, as carbolic, lactic, pyrogallic, or chloracetic acid. A strong 
solution of potassium hydroxide or mercuric nitrate, or an arsenical 
paste, may be employed. 

In a few cases electrolysis has been of benefit. Erasion with a 
dermal curette, as well as operation by multiple punctures or by linear 
scarifications, is of less value than in lupus vulgaris. Erasion has in 
some instances been followed by involution of the disease, but also, 
as a rule, by cicatrices that are no less disfiguring than the original 
disorder. 

Prognosis. — A favorable opinion with respect to the future of the 
disease can never safely be given ; though as regards the general 
health and comfort of the patient there can rarely be question. At 
the same time the affection is capricious in its course, and may on 
occasions, after long periods of persistence, rapidly improve under the 
simplest treatment. Spontaneous involution with disappearance of all 
symptoms is reported in some cases. The disorder is liable to relapse, 
though not to frequent recurrence. Its tendency to the production of 
persistent scars should always be remembered in formulating a prog- 
nosis. 



614 NEW-GROWTHS. 






SYPHILIS. 

(Gr. gvq and (j>ihog, a companion of swine : term coined for poetical purposes by Fracastor.) 

(Lues Venerea, Morbus Gallicus, Pox, " Bad Disorder." Fr., 
Verole; ItaL, Sifilide ; Ger., Lustseuche, Krankheiten 
der Franzosen; Span., Sifilis ; Swed., Radezyge.) 

Syphilis is a chronic and infectious disease not yet actually demon- 
strated as having a microbic origin, but its position among the infec- 
tious granulomata is practically established. Lustgarten, Doutrelepont, 
and others have demonstrated the presence of bacilli (resembling those 
found in tubercle) in papules, nodes, chancres, and secretions from 
syphilitic lesions ; but the strict requirements of science as to proofs of 
etiological value for these particular germs have not been satisfied with 
respect to this disease. Whether these micro-organisms or others are 
finally demonstrated to be the potent agency in producing syphilis 
when it is transmitted by the medium of a virus, it is at least certain 
that late investigations into the nature of lepra and tuberculosis lend 
strong support to the doctrine that the contagium of syphilis is due to 
the presence in its secretions of a species of bacterium. 

Syphilis has been described as an " imitator of other diseases." 
The manifestations of the malady are certainly protean in character, 
and they may occur in every organ and tissue of the body. These 
phenomena are both like and unlike the symptoms of non -syphi- 
litic diseases of such organs and tissues. It would, therefore, be more 
in accordance with facts to describe syphilis as a special mode of dis- 
ease. Its phenomena differ from other pathological phenomena chiefly 
in the syphilitic modality with w r hich they are impressed. After 
infection there is a different behavior of the living matter of which the 
body is constituted. Its mode thenceforward is temporarily changed as 
regards the process of disease. Hence the importance of recognizing 
this modality in relation to disease of the skin, and of ascertaining 
the limits within which this influence is both originated and exhausted. 

Bicord was first to classify the phenomena of syphilis in three dis- 
tinct stages. In the first stage, or primary syphilis, were included 
symptoms relating to the chancre and its accompanying adenopathy. 
In the second stage, lasting from the date of the onset of general 
syphilis during a period of about two years, were grouped symptoms 
that were, as a rule, superficial, symmetrical, and more or less tran- 
sitory. In the third, or tertiary, stage the symptoms included were, 
as a rule, asymmetrical, more profound, involving the subcutaneous 
and deeper tissues, and invading often not merely the skin, but also 
the osseous, cartilaginous, and other structures of the body, including 
the viscera. This simple scheme when first given to the scientific 
world revolutionized all previous conceptions of the disease, and has 
dominated the medical profession up to the present time. 

But there are objections to a continued acceptance of this scheme, 
based largely on its incompleteness. The distinctions it seeks to make 
are wholly artificial, are defined by poor limits, and so often are com- 
pletely negatived that they fail to explain the most important of accidents. 



SYPHILIS. 615 

To be consistent and to explain in part the violations of their time- 
schedule, the French have coined such phrases as " precocious/' " tardy/ 7 
" galloping/ 7 etc. Further, the mind once dominated by this scheme 
was educated to look for the evolution of symptoms within each of these 
artificial stages in a determinate order, e. g. y after the occurrence of 
macules succeeded papules ; after these, pustules, tubercles, etc., a 
progression rarely observed in any given case. 

The Symptoms of syphilis are best studied, as they are clinically 
displayed in distinct departures from the infection-moment, along lines 
which are not fixed, but between which symptoms are intermingled with 
varying shades of severity. The four chief classes which may thus be 
recognized include most of the clinical pictures of syphilis : 

I. Benignant Syphilis, with Superficial and Transitory Symptoms. — 
In this first class the skin-lesions of general syphilis are few and at 
times are even insignificant. A macular rash, for example, over the 
surface of the chest and belly, lasting for a few days or for a week or 
more, accompanied by ganglionic enlargement, after involution, leaves 
the patient for the remainder of life free from obvious signs of the 
malady. These instances are rare. 

II. Benignant Syphilis, with Superficial and more or less Persistent 
Symptoms. — In this class are to be catalogued most cases of the disease. 
Some cases relapse to it from the class previously described ; others, 
fewer in number, retrograde to one of the groups named below. There 
is throughout no cachexia, and the skin-symptoms of the affection are 
neither destructive nor deep. Their chief significance lies in the fact 
that they may persist or may recur until the disease, either as a result 
of treatment or of a decline due to other causes, ceases to manifest itself 
by any symptoms whatever. 

III. Malignant Syphilis, with Profound, Relapsing, or Persistent 
Symptoms that Ultimately Resolve. — In this group are collected those 
cases in which, with persistent or with recurrent symptoms gradually 
involving the deeper structures of the body, the system suffers to the 
extent of exhibiting the signs of cachexia. Patients in this class, by 
reason of efficient treatment or the reverse, are readily transferred both 
to the second class and to the fourth. 

IV. Malignant Syphilis, with Profound and Relapsing, or Persistent 
Symptoms that are Ultimately Destructive. — In this class are included 
the gravest forms of the disease : those exhibiting deep and destruct- 
ive cutaneous lesions ; those implicating the viscera, bones, and other 
structures ; those interfering with the integrity of organs by reason 
of either atrophic or degenerative changes succeeding a circumscribed 
or gummatous involvement of tissue. 

ISTo one of the groups of symptoms named above necessarily follows 
any other. The last-described group may occur within a few months 
after the appearance of so-called " primary syphilis/ 7 even though 
formerly included in the old nomenclature among those of late, or ter- 
tiary, type. Many cases, indeed, of grave syphilis are of the type de- 
scribed by the French as " precocious 77 ; that is, they develop symp- 
toms of gravity either before or soon Lifter the healing of the chancre. 




616 NEW-GROWTHS. 



Chancee. 

Every attack of acquired syphilis exhibits as a first symptom an 
infecting chancre, and every infecting chancre signifies syphilis. 

A chancre is that modification of the sound or of the pathologically 
altered skin or mucous membrane, preceded by a period of incubation, 
characterized by sclerosis, and accompanied by adenopathy, which con- 
stitutes the initial lesion of inevitable syphilis. Chancres usually appear 
upon or about the genital organs simply because these organs are most 
often exposed to the disease. These lesions may, however, occur upon 
any portion of the surface of the body. 

Chancres appear after a period of incubation — an interval of time 
between the date of exposure to the disease and the manifestations of 
its first symptom. This period averages twenty-one days, but it may 
extend from ten days to two months and even more. 

The chancrous modification may involve, as stated above, the nor- 
mal or the pathologically altered skin or mucous membrane. Upon 
previously sound surfaces chancres may appear, after an incubative 
period, as macules, papules, tubercles, erosions, fissures, or ulcers, each, 
or either of which, at some future period of its history is character- 
ized by a peculiar hardness of the tissues about and beneath the lesion, 
this condition being known as the " initial sclerosis." These symptoms 
vary according to the location of the chancre and the friction or other 
external irritation to which the lesion has accidentally been subjected. 
Generally it may be said that all chancres tend to conform to the 
papular type, the macule developing into the chancrous lesion, the 
tubercle being evolved from its exceptional enlargement, the ulcer 
from its degeneration, and the erosions or fissures from the accidents 
of its less pronounced features. Occurring upon mucous or quasi- 
mucous surfaces these lesions are influenced by heat, moisture, and 
friction (labia, prepuce, etc.). Here the superficial erosions are usually 
circular in outline, are very slightly depressed, and they rest upon 
delicate beds of sclerosed tissue, the so-called " parchment-induration." 
The papule is often represented by a tolerably well-circumscribed, 
macular discoloration of the membrane, where coarse examination 
would scarcely suggest elevation of the surface, with a sclerosis of no 
greater extent than that of the erosion, w r ith which it probably sustains 
a close relation. As a result of heat, moisture, and friction, however, 
the typically dry and scaling papule constituting the chancre of the 
integument is here rarely encountered. More often the lesion is a 
circumscribed ulcer with clean-cut walls, penetrating deeply to the 
derma or even below, with a scanty secretion and a reddish floor, rest- 
ing upon a split-pea-sized mass of sclerosed tissue. Other usual forms 
are superficial erosions, in themselves of insignificant aspect, surmount- 
ing large nodules, tubercles, or even long linear ridges of densely 
sclerosed tissue, undergoing repair or degenerating according to the 
condition of the patient and the treatment to which he has been sub- 
jected. These erosions are usually out of proportion to the size of 
the indurated mass upon which they rest. Such voluminous indura- 
tions are occasionally perforated by deep conical or funnel-shaped 






SYPHILIS. 



617 



ulcerations of formidable aspect, to which the name " Hunterian 
chancre " was once applied. 

Occurring upon cutaneous or mucous surfaces, where there has been 
a previous morbid process, the syphilitic mode is impressed upon the 
symptoms significant of such antecedent disease. This accident is 
sufficiently common, and the resulting lesions are as various as are 
those of different diseases. Thus, a man or woman may be infected 
with syphilis at the site of an herpetic vesicle upon the lip or the 

Fig. 71. 





Chancre of the tongue. 

genitals, such vesicle being unbroken and recent, or several days rup- 
tured ; or at the site of a balanitis ; or of a vegetation ; or of the soft 
contagious sore of the genital region best recognized under the term 
"chancroid." Or the inoculation may occur at the site of a trauma- 
tism ; for example, where the frenum is slightly torn in coitus, or where 
the bruised knuckle of the accoucheur is exposed during the practice 
of his art. 

The induration of chancres may precede, accompany, or follow the 
lesion with which they are associated. The sclerosis may be short- 
lived, persistent or recurrent, and in this respect may resemble the 



618 NEW-GROWTHS. 

chancre itself, which may endure but for a few days, or be in course 
of full evolution at the date of appearance of so-called " secondary " 
symptoms. 

As a consequence, the ganglia in anatomical connection with the 
chancre become, with very rare exceptions, enlarged and specifically 
indurated. With genital chancres there is usually double inguinal 
adenopathy ; with labial chancres, submaxillary adenopathy ; with 
chancres of the eyelid, pre-auricular adenopathy, etc. The glands 
usually enlarge within a few days after the appearance of the chancre, 
and remain in that condition for several months. They are indurated 
on one or on both sides of the body ; are freely movable ; are unattached 
to surrounding tissues ; are neither painful, tender, nor inflammatory, 
and they therefore terminate neither by suppuration nor by ulceration. 
It will thus be evident that the word " chancre " is applicable only to 
certain features assumed by other lesions, and is not itself descriptive 
of a lesion differing absolutely from all others. It is indeed clear that 
there can be no particular chancre-lesion, since in turn the macule, 
vesicle, pustule, papule, tubercle, erosion, vegetation, ulcer, and fissure 
may each become a chancre. Every other elementary lesion of the 
skin, therefore, may assume the chancrous features ; in other words, 
may display in its morbid career the modality of syphilis. These 
chancrous features are : infection ; sclerosis after an incubative period ; 
coincident or consequent adenopathy (sclerosis of neighboring ganglia) ; 
and, after a second incubative period, the occurrence of the symptoms 
of general syphilis. The last-named is, of course, an historical feature, 
not recognizable during the greater part of the life of most chancres. 

The minor chancrous features are less constant and trustworthy. 
Chancres of the skin may be deeply pigmented. Some are painful 
from the occurrence of inflammation ; some are injured by traumatism 
(chancre of the nipple in nursing-Avomen) ; some, by irritants (caustic 
improperly applied) ; some, finally, are so insignificant in feature 
(chancre of the vagina) that even the expert is readily deceived in their 
recognition. 

With or without involution and complete disappearance of the 
chancre, the symptoms of general syphilis occur only after a so-called 
" second period of incubation." This period extends usually from 
between the end of the first to the end of the second month after the 
appearance of the chancre, the average being between the fortieth and 
the forty-fifth day. During this period the general condition of the 
patient is that which, by subjective and objective phenomena, displays 
signals of the approaching distress of the economy. There are anaemia, 
and, in cases, even chloro-ansemia ; wandering pains, substernal or 
about the articulations ; a cachectic appearance ; engorgement of the 
superficial and deep ganglia ; occasionally a well-marked febrile pro- 
cess, the so-called " syphilitic fever " ; and a special irritability of the 
skin and mucous membranes. 

The so-called " periods of incubation " in syphilis do not, however, 
really exist. The words used to define them refer to periods of time in 
which, upon gross inspection, the evolution of the disease does not seem 
to be in progress, but in the course of which there is ample evidence that 






SYPHILIS. 619 

there is a gradual involvement of one portion of the body after another. 
Thus, in the "second incubative period" of the text-books careful 
examination of a patient about to display the external manifestations 
of systemic disease discloses the fact, as suggested above, that the symp- 
toms are by no means latent. The glands of many parts of the body 
beside those in the vicinity of the initial sclerosis become tumid and at 
times painful, including the tonsils and thyroid gland. The skin may 
exhibit icteroid symptoms as a result of hepatic disturbance ; the excre- 
tion of urea may be augmented or albumin may temporarily appear in 
the urine ; pains in the head, limbs, and other parts of the body may 
produce distress even of a severe grade ; the leucocytes may relatively 
increase in number ; the joints may become painful and swollen ; and 
muscular contracture with many other evidences of a morbid state of 
the system may indicate to the careful observer that a general process 
of intoxication is in more or less rapid evolution. 

At this moment, the " second incubative period " of the disease being 
completed, the patient is ready for an "explosion" of general syphilis. 
Insidiously or suddenly, first noticed upon the skin beneath the cloth- 
ing, with rapid efflorescence over the entire body-surface after a hot 
bath, the stimulus of liquor, or the excitement of the dance, appear 
the syphilodermata or syphilides or skin-symptoms of syphilis. 

Syphilodermata (Syphilides). 

The skin-manifestations of syphilis are of common occurrence, are 
numerous as to their forms, and are of the greatest importance from a 
diagnostic point of view. 

As in syphilis of other organs, that of the skin is betrayed in symp- 
toms like and unlike those of non-syphilitic affections. The study of 
these differences is here also a study of the syphilitic mode of disease. 
In a treatise of this scope and these limitations it will be practicable 
to describe merely those evidences of the syphilitic process to be recog- 
nized in the integument. 

Lesions of the skin appear in syphilitic individuals of both sexes, in 
all periods of life, and in all stages of the disease. These symptoms 
are, however, much more frequent during the first two years after infec- 
tion, subsequent to which period the symptoms of the disease are more 
commonly betrayed in subcutaneous lesions, or lesions which affect the 
viscera, and the osseous, nervous, muscular, and vascular systems. 

General Characteristics of the Syphilodermata. — The syphiloder- 
mata, like chancres, are, properly speaking, modalities of such symptoms 
as occur in diseases not syphilitic. The distinctive difference between 
the papules, ulcers, and other lesions of syphilis and those of lupus, 
for example, lies chiefly in the mode of evolution and involution. It 
is the syphilitic behavior, rather than the syphilitic lesion, which guides 
the diagnostician. The syphilides, in short, resemble the lesions of 
most of the other diseases of the skin, and they differ also in various 
degrees from each one of the latter. Hence is seen the importance of 
a clear recognition of their general characteristics. 

Absence of Subjective Sensations. — The eruptions produced by 



620 NE W- OR WTHS. 

syphilis are rarely attended by itching, burning, or painful sensations^of 
any sort. This absence is frequently a positive aid in establishing a 
diagnosis, and, as a rule, is the more valuable the graver the lesion. 
Great difference, however, will be noted in this respect between differ- 
ent individuals. Occasionally considerable itching will be induced, 
as in condylomata of the anus ; and syphilitic ulcers, especially of the 
leg, may be productive of severe pain. At the same time it is a com- 
mon experience to find a patient quite tranquil as regards all subjective 
symptoms, covered from head to foot with a brilliant macular syphilo- 
derm, or exhibiting with the utmost composure a large number of 
serpiginous ulcerations on his scalp and extremities. 

Polymorphism, a term used to designate the coincident appearance 
of lesions of various character upon one individual, is as true of 
syphilis as of other diseases, such as lepra and scabies. Viewing the 
cutaneous and other symptoms of syphilis as a whole, this feature is 
strikingly significant, as it is possible to observe at one and the same 
time, upon the body of a single infected individual symptoms indic- 
ative of pathological changes in the skin, mucous membranes, hair, 
nails, lymphatic glands, and periosteum. 

To a less marked degree is this true of the syphilodermata. The 
type of syphilitic skin-lesions is generally papular, and such lesions 
may originate from macules, enlarge into tubercles, or degenerate into 
ulcers. The simultaneous coexistence of several of these forms is due 
to their chronicity, to their tendency to recurrence, and to the changes 
which they undergo. 

Career. — The historical course of the syphilides suggests certain 
common features. They are rarely accompanied by local inflammation, 
and, with the exception of syphilitic fever, are usually unattended with 
pyrexia or with malaise. The tolerance by the general economy of an 
extensively developed syphiloderm is highly significant of specific in- 
fection. Again, though generally described as a chronic disease, syphilis 
is, judged with respect merely to time, much more acute than several 
other maladies. The syphilides have a distinct career, pursuing, even 
when untreated, a natural process of evolution and involution, and 
few, save those upon the lower extremities where the force of gravity 
is an important element in the fixation of all local disease, persist in 
unvarying type for any lengthened period of time. One lesion often 
succeeds another by development or by degeneration ; and many of 
the untreated syphilides disappear without leaving relics of their exist- 
ence upon the surface of the skin. In these last-named particulars 
syphilitic cutaneous manifestations are singularly different from those 
of lupus and of carcinoma, for example, where the lesion is usually of 
one type, and persists in one location for a period of time during which 
a syphilide would have progressed either to much more extensive 
damage or to permanent repair. 

Color. — There is no color peculiar to the syphilodermata that may 
not be seen in other diseases of the skin. It is important to recognize 
this fact clearly, as there are those who claim to diagnosticate the 
syphilides by their hue alone. The color, however, considered in 
connection with the other features of the syphilides, is highly char- 



SYPHILIS. 621 

acteristic, and often is sufficient to enable one at a glance to identify 
the disease. These color-shades are usually less brilliant than those 
seen in other dermatoses, and they possess less of the scarlet and pink 
quality. They are admixtures of red, yellow, and brown in various 
proportions, frequently with a slight preponderance of the brown. 
They have been compared with the color of raw ham and with that 
of copper, hues which unfortunately have been so associated with the 
syphilides that the no n -recognition of such tints has led to many 
errors in diagnosis. Pigmentation in various shades of chocolate, 
coffee, and black is recognized, both during the evolution and after 
completion of involution of the syphilodermata. In cases in which 
there has been no luetic affection the color, as in syphilis, is due to 
increase of pigment in the part, both with and without extravasation 
of blood. Recent syphilitic scars are usually pigmented both in centre 
and at the periphery. In these, again, it is not so much the color as it 
is the scar with, the color that gives special significance to such lesion- 
relics. 

Contour. — In syphilis the contour of single elementary cutaneous 
lesions, as also of a group of aggregated lesions, is usually circular, or 
there is a distinct tendency to assume such a configuration. Thus, it 
is common to find outlines of patches, ulcers, and scars observing the 
curve of a segment of a circle, and the coalescence of several such 
lesions tends to produce the serpiginous aspect. Figures resembling 
a horseshoe, a kidney, a half-moon, the letter S, and a dumb-bell are 
thus produced. The earlier exanthems of syphilis are usually sym- 
metrical, the latter asymmetrical. Even symmetrically distributed 
eruptions will at times occur in annular patches, made up of maculo- 
papular lesions arranged in a circular or a crescentic line. Patches of 
syphilitic eruption will often clear at the centre and develop or spread 
at the circumference of a circle. 

Site. — No portion of the skin is free from the possibility of invasion 
by syphilis. The disease may involve at once almost the entire integu- 
ment ; or it may rapidly spread from point to point, having covered 
finally a large area ; or it may appear conspicuously at distant and iso- 
lated points of limited extent ; or, finally, it may be manifested exclu- 
sively in an insignificant lesion or a group of lesions, ephemeral in 
course and limited to one portion of the body. The site of a syphilitic 
eruption may be determined apparently by the capriciousness of the 
disease, and yet result from local irritation of the skin of infected 
individuals. The accumulations on the napkins of women invite the 
occurrence of labial condylomata ; the lips of the infant, after contact 
with the nipple of the mother, become the seat of rhagades and fissures ; 
while the tongue of the tobacco-chewer and the fauces of the tobacco- 
smoker acknowledge special sources of mischief. 

There are some sites of preference for special lesions, as, for example, 
the squamous syphiloderm of the palms and soles ; and the papules of 
the forehead, constituting the so-called " corona veneris/' 

Amenability to Treatment. — Mercury possesses a singular influ- 
ence upon the syphilodermata that is promptly perceived when the drug 
is internally administered. This singularity rests upon the broad fact 



622 NEW-GROWTHS. 

that the lesions of many other cutaneous diseases not only refuse to ac- 
knowledge the benefit of such medication, but in many cases are even 
aggravated by it. The importance of clearly recognizing the character 
of each cutaneous disorder submitted to treatment is thus well illus- 
trated. 

Character of Special Lesions. — Certain families of symptoms 
in syphilis exhibit characteristic features. Thus, some papular lesions 
are surrounded at the base by a peculiar fraying of the epidermis, in con- 
sequence of which they are encircled by a little fringe of scales resem- 
bling in shape a collar. The scales of syphilis are usually not abun- 
dant, but are fine, dirty whitish or occasionally brownish in color. The 

Fig. 72. 




w' 
Facial cicatrices of tubercular syphilodermata after twenty-five years of infection. 

crusts of syphilis are apt to be bulky, greenish black in hue, and to 
surmount secreting ulcers of various depths. Such ulcers are gener- 
ally circular, or they exhibit in contour a tendency to assume the cir- 
cular line, while the cicatrices by which they are succeeded have a sim- 
ilar configuration. The scars of syphilis are frequently smooth, delicate, 
very slightly depressed, unattached to subjacent tissues, and pigmented. 
Lastly, from several of the secreting lesions of syphilis, especially those 
upon and about the anogenital region, proceeds a discharge having an 
offensive odor and capable of communicating the disease to a sound in- 
dividual. 

Subjection to External Agents Capable of Exerting an 
Influence upon Non-syphilitic Eruptions. — It is an obvious 



SYPHILIS. 623 

error to conclude that the exanthemata of syphilis are produced exclu- 
sively by the operation of a systemic intoxication. Many of the pustu- 
lar syphilodermata are the result solely of pyogenic cocci, and the 
extension of the eruption may be by inoculation and auto-inoculation. 
This fact is shown not merely by the ordinary methods of demonstra- 
tion, but also by the clinical fact that these lesions are far more frequently 
encountered among the filthy, the neglected, and the ignorant. Often 
syphilodermata are commingled with seborrheic and eczematous affec- 
tions. It is not rare to find patients applying for relief in clinical 
practice who exhibit lesions of syphilis commingled with traces of the 
incursions of lice and bugs, urticarial wheals, scratch-marks, and forms 
of keratosis pilaris, due to the unwashed condition of the skin. 

Syphiloderma Maculosum. — The cutaneous lesions of syphilis, limited 
to color-changes in more or less circumscribed areas of the skin, are 
exhibited in two distinct forms, due respectively to anomalies in blood- 
supply and pigment-distribution. 

Syphiloderma Maculosum due to Hyperemia (Erythem- 
atous Syphilide, Syphilitic Roseola). — This form of macular 
syphiloderm is the earliest expression of systemic cutaneous syphilis, 
and is more or less constant of occurrence, differing in this respect from 
several of the other syphilides. It is often unnoticed by the patient, 
whose attention may first be called to it after its recognition by the 
skilled eye of another. It occurs in coffee-bean- to filbert-sized mac- 
ules, roundish, oval-shaped, or of irregular contour, and varying in color 
from a light rosy to a dull mulberry hue. In some cases these markings 
of the skin-surface are very indistinct, requiring for their recognition 
the closest scrutiny in a clear light, and occasionally even then leaving 
uncertainty in the mind of the expert. With a lens tinted in cobalt- 
blue they may be recognized at an earlier date than if viewed with the 
unaided eye. At times they constitute an irregular " marbling " of the 
surface, of a kind which renders it difficult to define with the eye the 
individual lesions composing the eruption, while the general visual 
effect of the exanthem is distinct. The spots are not elevated above 
the general level of the integument, but may change in type, a papular 
lesion developing later in the same site. 

Like all macules of the skin due to vascular changes, those of 

syphilis vary in color with the complexion of the individual, with the 

1 time which elapses after their first appearance, and with vascular 

I changes in the superficial plexus of blood-vessels. Thus, the deeper 

shades are usually observed in thick and muddy-tinted skins ; the more 

delicate tints upon the breast, for example, of blonde women. 

BThe eruption usually appears between the sixth and the eighth week 
after the appearance of the initial sclerosis, and, when untreated, de- 
velops for about one week more. It persists for a variable period of 
time, depending upon the severity of the constitutional disorder and 
the treatment to which the patient is subjected. During the early 
part of its career the hue of the lesions is lighter, and they may be 
made to disappear under pressure of the finger ; later, they are more 
deeply stained, and, exudation having occurred, the color of the spot 



624 NEW-GROWTHS. 

does not disappear under pressure. When involution is in progress 
there is a slow disappearance of the eruption, which gradually fades 
from view. The vascular changes in the capillaries occasioned by 
cold, heat, and rapid cardiac contractions, influence the eruption to a 
marked degree. A hot bath, a dance, a glass of spirits, a fit of excessive 
coughing, laughter, etc., may all bring the lesions into prominence. 

The eruption may be limited to the skin of the belly, extending 
sparsely over the chest, the loins, the anogenital regions, and the 
thighs ; may develop over the palms, soles, forearms, and legs ; or, in 
exceptional cases, may profusely cover the entire surface of the body 
(face, ears, dorsal surfaces of the hands and feet, and skin of the penis 
with the progenital region). In the milder forms it is evidently sus- 
ceptible to external irritation of the skin, as it is common at the wrists 
where a starched cuff is worn, over the brow in the line in contact with 
the hatband, and is particularly well developed in men where the 
trousers are " reinforced " (perineum and inner faces of the thighs). 

At times, as in the exanthematous fevers, the eruption is preceded 
by a febrile state, with marked amelioration of symptoms when the 
rash is fully developed ; while, again, it is throughout accompanied by 
slight rise in the body-temperature, the patient having the so-called 
"bilious" appearance — muddy complexion, coated tongue, icteroid 
hue of conjunctivae, and offensive condition of the breath. Wander- 
ing pains in the extremities, and especially beneath the sternum, are 
frequently experienced. The last-mentioned symptom is highly sig- 
nificant, and the whole condition is probably due to the effect upon 
the nervous system of the circulation of the recently intoxicated blood. 
These pains are not those produced later in the periosteal and other 
complications of the disease, and are the more significant as the erup- 
tion itself is productive of a scarcely appreciable subjective sensation. 
The superficial ganglia of the body are usually engorged at the same 
time ; the fauces are congested ; the hairs of the scalp are slightly 
loosened in their follicles, and in the latter region in severe cases 
papules and pustules may form. Inasmuch as the order of sequence of 
most of the phenomena in syphilis is subject to a singular inversion, it 
occasionally happens that there is concomitance of later signs of the 
disease, such as iritis, affection of the nails and bones, or even, in special 
regions, of pustular, papular, or squamous syphilodermata. 

Much less rare is the survival of the initial sclerosis to the date of 
this efflorescence. This point is of considerable importance. The 
physician should never conclude the examination of a patient com- 
plaining of suspicious genital lesions without carefully exploring the 
surface of the trunk, and also never pronounce upon an exanthem of 
this sort without minute inspection and palpation of the part where 
an initial sclerosis may exist. In a diagnostic and therapeutic sense 
the information thus gained may be precious, and in a large proportion 
of all cases is of a kind hidden from the knowledge of the patient. 

Relapses occur in certain cases with limitation of the disease to parts 
previously affected or unaffected. At the end of the first twelve 
months recrudescence of larger macules in annular groups may occur. 
Exceptional forms are noted in which darker puncta appear in the 






SYPHILIS. 625 

macular lesion, occasionally traversed by a hair. These puncta are 
localizations of a more intensely hypersemic or exudative condition 
about the orifices of the ducts of the follicles. 

The diagnosis of this syphiloderm is readily established in view of 
its essentially symptomatic character. From scarlatina, measles, and 
rotheln it differs in the indolence of the rash, the absence of decided 
elevation of body-temperature, and the order of its appearance in dif- 
ferent portions of the body, as it rarely occurs first upon the face. Ur- 
ticaria and the rashes induced by the ingestion of copaiba and other 
medicaments are distinguished by the marked itching of the affected 
surface and by their very general diffusion over the entire body, a con- 
dition rarely observed in the syphiloderm. Tinea versicolor, usually 
limited to the anterior surface of the trunk, is characterized by a fawn- 
colored to a chocolate-colored tint, by the furfuraceous desquamation 
which the patient usually describes as most noticeable after a hot bath, 
and by the existence of the readily recognized vegetable parasites upon 
the scales scraped from the affected surface. Tinea versicolor is, more- 
over, of much longer duration than a syphiloderm, and almost never 
extends to the exposed parts of the body — the face and the hands. 
Ringworm of the skin of the body is not symmetrical, and is a para- 

^ sitic disease. 

Ail these distinctions, however, are not to be compared in diagnostic 
value with the concomitant symptoms of syphilis that are very generally 
present, such as adenopathy, persistence of the initial sclerosis, and 

[l evident involvement of other than cutaneous tissues. Such concom- 
itant symptoms will be found occasionally with a non-syphilitic erup- 
tion due to drugs ingested for relief of the infectious disease. The 
most common of these drugs is potassium iodide ; the eruptions it pro- 

j duces are frequently found both commingled with the macular syphilo- 
derm and occurring on the eve of the appearance of the latter. The 
existence of acneiform lesions upon the face, the neck, and the posterior 
surface of the trunk, a vivid erythema of the forearms, including the 
hands, and purpura-like maculations of the face, legs, and feet, should 
never mislead the physician as to the character of the disorder with 
which he is confronted. It is undeveloped syphilis with a dermatitis 
medicamentosa of the surface. Suspension of the iodide, which drug 
fortunately is not required in the majority of cases ; the use of a properly 
selected mercurial, or even (and this is often wise) abstention from all 
medication, will be succeeded by disappearance of the cutaneous lesions, 
which may be followed later by a mild macular syphiloderm, altogether 
insignificant in comparison with the eruption artificially induced. 

Syphiloderma Maculosum due to Anomalous Distribution 
of Pigment (Pigmentary Syphilids). — This eruption, if it may 
be so called, is occasioned by the appearance upon the body-sur- 
face of irregularly circular, usually poorly defined, dirty-brown and 
chocolate-tinted macules, which, as they are unconnected with vascular 
changes, do not disappear under pressure. The lesions occur as sparse, 
well-isolated dis colorations, or, more commonly after a species of con- 
fluence, as an irregular rete or network, with relatively large inter- 
spaces characterized by an absence of coloration. The eruption is most 
40 



626 NEW-GROWTHS. 

common upon the sides of the neck, the shoulders, and breasts of blonde 
women, though it may more rarely involve the surface of the trunk and 
the extremities. It is often recognized, however, among Anglo-Saxons 
of brunette type, and also among negroes, mulattoes, Indians, and per- 
sons of the Mongolian race. It is most frequent during the first year 
after infection, though it may develop later. 

It occurs (a) as a sequel to a macular or maculo-papular syphilo- 
derm over the parts described above ; and (b) ab origine, as a pigment- 
disorder, probably under the same influences as those productive of 
the chloasmata of symptomatic origin (chloasma uterinum, cachecti- 
corum, etc.). 

The color-changes observed in the skin are explained by the occur- 
rence : first, of pigmentary deposits, chiefly at the centre of the ordi- 
nary macular or papular syphiloderm ; secondly, of peripheral absorp- 
tion of such pigment-deposit with possible persistence of it for a varia- 
ble time at the centre of the lesion ; thirdly, of total absorption of all 
pigment from the original lesion ; and lastly, of peripheral hyperpig- 
mentation of the spaces intermediate between the original macules. 

The eruption is an epiphenomenon of the syphilitic process, being 
not amenable to the treatment under which other macular syphiloder- 
mata speedily disappear, and is an expression rather of general deteri- 
oration of the health of the skin than of specific disease. 

The eruption is liable to be mistaken for that condition in which 
there is simply an accumulation, upon a somewhat greasy skin, of 
secretions and dust, to be seen upon an integument long unwashed. 
Tinea versicolor has a more yellowish or fawn-colored tint, and is more 
abundantly developed upon the front of the chest than upon the neck. 
Neither vitiligo nor leucoderma is symmetrically disposed, as is usually 
the case with the pigmentary macular syphiloderm. 

Syphiloderma Papillosum. — The type of all cutaneous lesions pro- 
duced by syphilis is to be recognized in the papule. Most of the 
other lesions are either developed from it, transformed to it, or by 
reversion or admixture confess that the neoplasm of syphilis in the 
skin is essentially a more or less solid circumscribed cutaneous lesion, 
varying as to size and history. 

Papules occurring in syphilis may appear as the first cutaneous 
evidence of infection, or they may be developed from earlier macules. 
They may be small, large, acuminate, flat, disseminated, or in" groups. 

Small Acuminate Miliary Papular Syphiloderm. — In this 
eruption the lesions are millet-seed- to hemp-seed-sized, circumscribed, 
globular, acuminate, reddish and salmon-reddish, firm elevations of the 
surface, or minute nodules upon the skin, generally symmetrically 
developed, often over the entire body, closely set and occasionally 
grouped in crescentic figures. When viewed with care a minute vesicle, 
a pustule, or a scale may often be detected at the conical apex of each 
papule, the vesicular or pustular lesions rarely developing to such an 
extent as to become a characteristic feature of the eruption. The 
color is at first, especially in blonde skins, a species of salmon and 
red mixed; later, the darker and browner shades appear. When 






SYPHILIS. 627 

generalized the eruption is well developed, especially over the posterior 
surface of the body, the occipitocervical and scapular regions, the but- 
tocks, and the calves of the legs, though it is often distinct about the 
anus and the genitalia. Like several other of the syphilodermata, its 
earlier are more symmetrical than its later manifestations, whether 
these be tardy or relapsing, or both. The involution occurs by resorp- 
tion of the plastic exudate, minute and usually scanty, dirty- whitish 
scales encircling the base of each lesion. When the eruption has 
proved especially persistent, marked pigmentation follows in the form 
of brownish-red blotches, the centre of each of which displays a cicatri- 
form relic in the form of a punctum. 

The eruption is often first noticed about the forehead, nose, mouth, 
and neck, localities commonly subject to topical irritation. Thus, about 
the forehead in men the papules will frequently be arranged along the 
surface pressed by the lining of the hat ; and frequent fingering of the 
face, shaving, and irritation by the edge of the collar of the shirt 
may determine a more speedy efflorescence at the sites of contact. 
About the mouth tobacco plays the part of an excitant; about the nose 
a localized seborrhcea may be added to the syphilitic phenomena, in 
which case the lesions may be covered with thin greasy crusts. The 
eruption is common during the first six months after infection, and is 
usually fully developed after a fortnight when no treatment has influ- 
enced its evolution. When the lesions are perforated by hairs they 
suggest on superficial examination a resemblance to keratosis pilaris ; 
and when aggregated in patches of distinct contour they may be con- 
founded with psoriasis or squamous eczema. But in every case the 
general physiognomy of the disease may well be trusted for the estab- 
lishment of a diagnosis, having in mind the color, the absence of intense 
pruritus and serous exudation, the disposition over the body as a whole 
or in portions widely separated, and the rarely failing concomitant evi- 
i dence of syphilitic infection. 

Large Acuminate Papular Syphiloderm. — Lesions of the 
character above described occasionally develop to an unusual extent, 
attaining the size of that of a coffee-bean in localities where the apex 
of each lesion is free to push forward without coming into contact with 
adjacent planes of the integument. Thus, about the dorsum of the 
body, the gluteal regions, the calves of the legs, and the extensor sur- 
faces of the forearms, fully developed, slightly scale-capped or scale- 
encircled, and grouped papules may appear, often commingled with 
pustules and superficial ulcers, the polymorphic patch having a figure- 
of-eight or S-shaped outline. These patches are often displayed by 
patients under treatment the influence of which has interfered with the 
full evolution of the disease. 

Small Flat Papular Syphiloderm. — The lesions recognized 
under this title differ from those just described in that they are not 
acuminate, but are distinctly flattened at the apex, this flattening being 
at times so pronounced that each lesion resembles a small button or a 
plaque, the contour being roundish or oval-shaped. The lesions are 
frequently encountered on the face, especially near the mucous outlets, 
over the anterior and posterior surfaces of the trunk, and on the flexor 



628 NEW-GROWTHS. 

aspects of the extremities. The palms of the hands are often affected. 
In color the papules exhibit the variation usual in individuals of dif- 
ferent complexions, and in the same individual as they are related to 
the condition of the circulation. Thus, on the face a scarcely distin- 
guishable pink will become a deep, lurid, reddish brown from an attack 
of sneezing, a paroxysm of laughter or of rage, and from violent exer- 
cise. The seborrhoe'ic condition noted on the face in the acuminate 
lesions is also occasionally seen about the plaques. The same is true 
of the scaling described above. The eruption is much less copious, as a 
rule, than with other forms of syphilitic papules, due doubtless to the 
fact of its frequent occurrence in those subjected to treatment. The 
papule differs from the lesion about to be described with respect to its 
size, being rarely larger than small buttons ; while the largest papules 
of the same variety may attain the size of large coins. The diagnosis 
has already been suggested. 

Large Flat Papular Syphiloderm. — Here the resemblance of 
the papule to a button is even more distinct, the lesion occurring with 
a well-defined, firm, raised border, and a shallow depression in the 
centre, though at times, especially in moist situations, the superficies 
of each plaque is a smooth, flat plane. The large papules commonly 
begin as macular lesions and rapidly develop at the periphery, this 
development often corresponding with centric involution, by which the 
shallow depression described above is reduced to the level of the adja- 
cent skin and the lesion is transformed into a ring. In shape the 
papules are circular and oval ; in size they vary from that of a finger- 
nail to that of a pigeon's egg. They have the usual variation in color, 
and may scale at the edge, or over the flat top or the depressed centre. 
In moist situations they frequently secrete a muco-purulent fluid which 
is smeared over the papules and adjacent integument, and which, in the 
vicinity of the anus or genitals, exhales an offensive odor. It is especially 
in such situations that flat papules of the type described occasionally 
degenerate by fissure or by circular ulceration. Condylomata Lata 
are flat and secreting papules of the regions named, which have a whit- 
ish appearance in consequence of the mucoid secretion with which they 
are smeared, and which are transformed by the influence of heat, moist- 
ure, and either friction or apposition of contiguous integumentary folds. 

Papular syphilodermata may become generalized or be limited to 
certain sites of preference, as the face, the neck, the flexor surfaces of 
the extremities, and the anogenital region. The eruption is either an 
early, a late, or an intermediate symptom of syphilis, occurring most 
abundantly in young and delicate skins, where the disease has been 
ignored and therefore untreated; and most scantily in the thicker 
integument peculiar to middle life, where prompt resort has been had 
to appropriate medication. 

Syphilitic papules undergo a series of modifications under the influ- 
ence of various causes which may be enumerated as follows : 

(a) There is considerable hyperplasia of the cutaneous elements 
(papillary layer of the corium, rete, and blood-vessels), by which the 
papule becomes largely raised from the surface, so as to resemble a 
papilloma, wart, or the lesions characteristic of iramboesia, In this 



SYPHILIS. 629 

way, rarely, a portion or the entire surface of the body may be cov- 
ered with light-red or violaceous-red, non-ulcerative, vegetating growths. 
They secrete freely, and the discharge is liable to concrete into crusts 
and to exhale an offensive odor. 

(6) There is considerable hyperplasia of the elements, in conse- 
quence of which the lesions spread laterally, while their elevation from 
the surface is prevented by contact with apposed surfaces. Thus is 
formed the broad, flat, moist papule known as the " vegetating mucous 
patch," " condyloma," plaque muqueuse, etc. (Fig. 73). The lesions, 
when unaltered and fully developed, are of a whitish color in conse- 
quence of the puriform mucus which covers them, and which, as with 
so many of the syphilodermata in moist situations, is liable to exhale 
an offensive odor. When the secretion is removed the lesion is seen 
to be pinkish, or light or dark red in color, and to be either firm or 
soft, scarcely raised, and indefinite in contour, or distinctly elevated 

Fig. 73. 





Vegetating condylomata oi the vulva. (After Jullien.) 

and well defined. Condylomata are chiefly found in moist situations 
where folds of the skin are apposed, as about the perineum, the groins, 
the axillae, the mammae, the nates, the anus, the genitals, and the inner 
faces of the thighs. They may coalesce to form palm-sized patches ; 
and frequently they are associated with hyperidrosis, seborrhcea oleosa, 
and the dried products of secretion from the adjacent mucous outlets. 

(c) In consequence of changes in the superficial layers of the epi- 
dermis the papules may become covered with scales, either at the base 
or the apex, more commonly the latter, forming thus the papulo-squa- 
mous syphiloderm. The scales are of a dirty-grayish hue, often des- 
iccated, generally attached, rarely freely exfoliating. They are rela- 
tively few, occurring where the lesions are closely set. The desqua- 
mation may be the most suggestive feature of the patch. Beneath 
the scales are seen distinctly elevated brownish-red papules or merely 
slightly elevated, dull-red or purplish-red maculations. When the 
scales accumulate at the base of the papule they tend to surround it 
with a circlet or collarette of exfoliated shreds of epidermis. 

Palmar and Plantar Syphilides. — In consequence of the thick- 
ness of the epidermis in the palms and soles the papular or papulo- 



630 NEW-GROWTHS. 






squamous syphiloderm of these regions is presented under somewhat 
atypical forms. The dense stratum corneum of the epidermis in the 
palms and soles is not readily raised from its underlying tissue into 
papular forms. The pathological manifestations of this disease are 
rather displayed in thickenings, separations, stainings, and frayings. 

Here, therefore, are seen dull-red maculations, covered throughout, 
or merely at the edges, by scales or epidermal shreds ; minute, firm, 
corneous thickenings, few or many, often without color in consequence 
of the depth of the blood-vessels beneath the opaque horny layer ; and 
distinctly elevated (not flattened) and circumscribed papules, of the 
usual livid-red color, coffee-bean- to small-nut-sized, often aggregated 
in patches having a tendency to assume the circinate outline. Occa- 
sionally with a pointed instrument pinhead-sized and larger deposits 
resembling chalk may be pried from circular beds in the palms and 
soles where the lesions first developed. These and similar spots are 
often covered with dirty-whitish, often tenacious, half-loosened, epi- 
dermic flakes which are characteristic. In other cases, usually in con- 
sequence of the motions of the hand or the foot, or the exigencies of 
toil, irregular angular losses of epidermis occur resembling the fracture 
of a pane of glass. The attached portions of the epidermis project 
at the edges only, over deep fissures, broad exulcerations, or a ham-red, 
tender, and newly formed epidermic stratum. 

The eruption is frequently symmetrical in the centre of both the 
palms and the soles, but is rarely found upon the dorsum of the hands and 
the feet, and then never developed typically, but always by extension 
from the palmar or plantar regions ; it is also seen on the lateral sur- 
faces of the hands, feet, fingers, and toes, as well as over the wrists 
and ankles. The exanthem is a persistent, rebellious, and usually 
late cutaneous symptom of syphilis, occurring often six, eight, and 
more years after infection. Rarely it is seen within a few months after 
the existence of chancre, and is then usually manifested in its simpler 
forms. 

The papulo-squamous syphiloderm bears in many instances a strong 
resemblance to the patches of psoriasis, but it can usually readily be 
distinguished from the latter by a consideration of the following points : 

The syphilide, as a rule, is not generally diffused ; it displays sym- 
metry only when it involves the palms and soles, and then not invari- 
ably ; it is elevated at the border of the patch ; and it observes the 
contour of the segment of a circle. Psoriasis is more widely dif- 
fused ; is generally symmetrical ; does not specially exhibit elevation 
at the border of the patches, and the latter are rather more completely 
than partially circular in outline. In syphilis there is generally a his- 
tory of infection, of other cutaneous or mucous symptoms of the dis- 
ease, and, in married women, of abortions, miscarriages, or births of 
diseased children, all of which symptoms are wanting in psoriasis. In 
psoriasis there is a decided predisposition to the development of the 
disease about the extensor surfaces of the joints and the posterior 
aspect of the trunk ; the syphiloderm, though it may occupy these 
situations, can rarely be found thus displayed when other surfaces are 
spared. The scales in psoriasis are more lustrous, are more freely pro- 



SYPHILIS. 631 

duced and shed, and they exist significantly at an earlier period of the 
exanthem. With only such exceptions as prove the rule, psoriasis 
is never strictly limited to the regions of the palms and soles. A 
scaling palmar or plantar disease of the skin in childhood is more 
likely to be psoriasic, though both diseases are seen in the early periods 
of puberty. 

Eczema is yet more readily recognized by its severe itching, its his- 
tory of discharge and moisture, and its characteristic crusts. Ancient 
patches of squamous eczema are often very indeterminate in outline ; 
they do not ulcerate, and they exhibit scales on the surface of a much 
more deeply infiltrated area. Eczema of the palms and soles, when 
chronic, usually involves also the dorsum of the hands and the feet. 
When this is not the case the eczematous infiltration, if of long dura- 
tion, will in the vast majority of all cases be found to involve uni- 
formly and evenly the entire palm or sole, including the palmar or the 
plantar faces of the digits. Eczema, finally, is much more frequently 
encountered solely upon the right hand in right-handed patients, or to 
a greater extent in that organ by reason of its preference in the per- 
formance of function. This is less common in syphilis. 

Syphiloderma Vesiculosum. — Vesicular syphilodermata are either the 
rarest of all cutaneous symptoms of syphilis or they do not actually 
exist. Certain French authors describe pinhead- to pea-sized, conical, 
globoid or umbilicated, isolated or grouped, and crusting elevations of 
the epidermis, with lucid or cloudy contents, seated upon the face 
and the genitalia. The eruption is described as an early syphiloderm, 
often exhibiting a halo of characteristic tint, the resulting crusts being 
granular and somewhat lighter in color than those commonly seen in 
the disease. Both small and large vesicles have thus been assigned to 
the disease. 

But the larger number of the lesions are, without question, either 
immature pustules, eczematous lesions in syphilitic subjects, or pure 
accidents of the syphilitic process. With regard to the first, it may 
be said that the pustular syphiloderm not rarely begins as a vesicular 
lesion ; with regard to the second, that coincidence of so common a 
disease as syphilis with other cutaneous disorders is a matter of fre- 
quent observation ; and with regard to the third, bearing in mind the 
large quantity of potassium iodide swallowed for the relief of the dis- 
ease and its capability of exciting a vesicular eruption, it can reasonably 
be concluded that some, at least, of the cases of so-called " vesicular 
syphilis " have imperfectly been studied. 

Syphiloderma Pustulosum. — In some of the pustular syphilodermata 
the pus is neutral ; in others the staphylococcus pyogenes aureus and 
albus are present. The larger number of all pustular affections of the 
skin, whether in syphilitic or in non-syphilitic subjects, are the results 
of infection with pus-cocci. It is therefore not sufficient in syphilis to 
pronounce upon the question of infection only. It is necessary further 
to explain many of the external phenomena of the disease by the acci- 
dents to which non-syphilitic patients are subject. 



632 NEW-GROWTHS. 

These accidents are probably of more frequent occurrence in pus- 
tular syphilodermata than in any other lesions exhibited in the disease. 
Viewed as a whole, it is noticeable that pustules occur for the most 
part in dispensary and hospital practice, among the impoverished, the 
filthy, the ill-housed, and the poorly treated. They are decidedly rare 
in the clientele of the physician consulted chiefly by those who are 
cleanly, well-nourished, and skilfully treated. If it were possible to 
keep the skin of the syphilitic subject aseptic during the management 
of the disease, no one would expect an evolution of pustular syphilo- 
dermata at any time throughout its course. The lesions described 
under this title may therefore be regarded for the most part as due to 
the causes suggested above, aided by picking and scratching the skin 
to an extent capable of distributing staphylococci over its surface. In 
other cases it cannot be denied that pustules, general of evolution and 
characteristic in appearance, may develop in consequence of luetic 
infection only ; but even of this type they are rarely to be seen in the 
better class of patients. 

Pustular lesions in syphilis further present a wide range of dif- 
ferences. They may vary in size from that of a pinhead to that of a 
finger-nail ; they may be acuminate, flat, hemispherical, or irregular in 
shape ; they may be few or be very numerous ; they may be distinctly 
localized or be generally dispersed ; they may be grouped or be dis- 
seminated ; and they may occur from the first as minute vesico-pustules 
or as pustular transformations of variously sized papules. They may 
be surrounded by inflammatory areolae, or may spring from an unaltered 
integument, or be subepidermic in situation, and scarcely project from 
the surface. They may be seated upon superficial or deep, or sharply 
cut, secretory ulcers, and they are usually covered with crusts differing 
in bulk and consistency, forming thus the pustulo-crustaceous syphilide. 
According to the depth of the ulceration at the base are they followed 
by cicatrices. Pigmentation is a frequent result. The crusts which 
form by the desiccation of pus are usually reddish brown to greenish 
black in hue ; they occur in strata or laminae by accretions from beneath, 
and, even when superimposed upon a moist and secreting ulcer, they 
are adherent at the edges. They may occur early or late in the dis- 
ease, and at either epoch may constitute trifling or grave cutaneous 
lesions. They have a marked predisposition for involvement of the 
sebaceous and pilary follicles, and they are frequently disposed about 
the mucous outlets of the body. 

Small Acuminate Pustular Syphiloderm. — This exanthem, 
which is usually largely diffused over an extensive surface, probably 
represents, as Jullien has suggested, a transformation from papular 
lesions, due to pus-infection in skins that are usually unclean, irritated, 
or the seat of diminished vitality. The eruption is certainly rare in 
patients of the better class. The pustules are generally recognized 
about the pilo-sebaceous orifices, and upon minute papular lesions, 
which, as undisguised elements of the eruption, may be interspersed 
among the latter. The pustules are acuminate and contain each but a 
droplet of cloudy serum or pus, the desiccation of which furnishes a 
thin yellowish or reddish-brown crust. The fall of the latter exposes 



PLATE XXI. 




•Large Pustolo-crustaeeous Syphiloderm of the Scalp and Body. 



SYPHILIS. 633 

the grayish epidermal fringe of the base occasionally seen in papules 
of similar size. 

The lesions may be discrete, confluent, disseminated, or in groups 
affecting the curve of a circle. The extremities and the trunk are 
chiefly involved, though the disease may be well-nigh universal. 
Under the influence of treatment occur minute, punctiform, and pig- 
mented cicatricial atrophic depressions which are not persistent. The 
eruption may be an early or a late secondary symptom, but usually it 
is first seen within a few months after infection. Relapses occur when 
treatment has irregularly been pursued. Frequent concomitants are 
those symptoms of syphilis proper to the period in which they appear. 

Large Acuminate Pustular Syphiloderm. — Under this title 
are classed lesions that are usually coffee-bean-sized pustules, which may 
spring from macular or smaller pustular lesions, very rarely from an 
indurated or a papular base. They have a thin roof-wall, occurring by 
preference where the epidermis is delicate, and they are surrounded by 
a halo. They are usually acuminate, but they may after full evolution 
slightly flatten at the apex in consequence of partial collapse. The 
crusts are bulkier and darker in color than those of the lesions just 
described ; their bases are superficially ulcerated. The pustules form 
slowly or rapidly, in disseminated or in grouped forms, usually at an 
early period of the disease, though commonly after the appearance of 
some syphilide of another type. 

Small Flat Pustular Syphiloderm. — This is a relatively 
frequent manifestation of syphilis, occurring upon the face, the scalp, 
the trunk, and the flexor surface of the extremities. The exanthem 
exhibits a decided tendency to characteristic and circular grouping 
about the mucous outlets of the body. Such groups are composed of 
small, flat pustules, originating as reddish, macular lesions which tend 
to dry into flattish, irregular, adherent crusts. These crusts either 
exceed the limits of the diseased surface beneath, or are conspicuous 
upon a dull brownish-red area of inflamed, and at times even of ulcer- 
ated aspect. 

Often the pustules are so closely set as to become confluent, in which 
case a single convex crust, like a carapace, will completely cover the 
involved area. Frequent sites of the exanthem are the regions about 
the nose and the lips, as also the chin, cheeks, and the anterior faces of 
the elbow- and wrist-joints. 

The eruption is of pustulo-crustaceous type, and it may be evolved 
from either papular or macular lesions. It is rarely long untreated, 
and is therefore not often presented for observation when in full evolu- 
tion. It is usually amenable to judicious treatment; when followed by 
severe ulceration, destroying an ala of the nose or a part of the lip, the 
j patient has usually suffered from either cachexia or neglect. In these 
cases less severe phenomena are presented in the superficial serpiginous 
syphilide, the lesions extending in circinate or annular gyrations about 
a sound or a previously involved and healed centre. Thus, a circlet 
of crusts, with underspreading superficial ulceration, perhaps alternating 
with pustules of various ages and reniform cicatrices, will surround the 
elbow or traverse the scalp. The resemblance to pustular eczema is at 



634 NEW-GROWTHS. 

times suggestive, but the ulceration and outline will aid in their recog- 
nition. The lesions are usually late among the earlier symptoms of 
the disease, but they may be delayed for six months after infection. 
They indicate, as a rule, either severity of the disease, or, much more 
commonly, constitutional impairment. 

Large Flat Pustular Syphiloderm. — The lesions classed under 
this title are fully developed forms of those described above. They 
originate as usually numerous, maculo-papular lesions, or as nodules or 
tubercles which gradually deepen into pea-sized and even larger flat 
pustules, the further history of which is one of enlarging, blood-mixed, 
reddish- and greenish-brown, also flattish, crusts with underspreading 
pus-bathed ulceration of varying extent. The superficial variety of this 
syphiloderm is distinguished from the deep chiefly by the extent of its 
ulcer, the size of its superimposed crust, and the lighter, dull-red areola 
which encircles it. 

The deep variety, Mke the superficial, may be limited to the scalp, 
face, neck, and flexor aspects of the extremities, or it may be much 
more widely diffused. The entire surface of the body is covered with 
discrete lesions of this type in cases of unusual neglect or of profound 
cachexia. The eruption is usually of late occurrence, but in the 
so-called " galloping syphilis"' of the French it may be precocious in 
development. The lesions are at the onset nodular or tubercular and 
become transformed into pus. They have each a deep infiltrated base 
with a dark-brown halo. Incrustation follows with the formation of a 
conical, roundish, or oval-shaped, blackish-brown crust, beneath which 
lies a clean-cut ulcer, the sharp edges of which are usually exactly 
roofed by the incrustation. The crust thickens by concretions from 
the foul and purulent ulcer beneath, and spreads at the periphery while 
it thickens in the centre. In this way the appearance of the stratified 
crust resembles that of an oyster-shell, a condition described by some 
authors as Rupia, a term once employed as the name of a disease. 
The ulcer, exposed after removal of the crust, is of characteristic 
syphilitic type in its deep base, foul floor, clean-cut edges, and puru- 
lent secretion commingled with blood, at times attaining a diameter of 
several inches, and having a circular, reniform, or horseshoe-shaped con- 
tour. The degree of destruction it may produce is inversely proportioned 
to the constitutional vigor of the subject and the treatment pursued. It 
is usually a grave and may be a malignant exanthem, though under 
favorable circumstances it is amenable to judicious treatment, and may 
be an early, though oftener it is a late symptom of the disease. The 
pigmented scars left are characteristic and indelible. 

Syphiloderma Bullosum. — Bullae in acquired syphilis are late and 
relatively rare lesions. They are pea- to large-nut-sized elevations of 
the epidermis, filled at first with a cloudy serum, which is soon trans- 
formed into pus, often mingled with blood. They have usually a char- 
acteristic halo about the periphery ; are roundish or oval in contour ; 
are usually discrete, rarely disseminated ; and after development they 
produce characteristic crusts with underlying ulcers, identical in feat- 
ures with the rupioid .sequels of large syphilitic pustules. The eruption 



PLATE XXII. 




Tubercular Syphiloderm, Resolutive and Serpiginous. 



SYPHILIS. 635 

is localized by preference upon the extremities, more particularly the 
lower extremities, and is indolent in its course. It is always significant 
of a cachectic condition in the subject of the disease. Its frequent 
occurrence in congenital syphilis is described later. It is to be distin- 
guished from pemphigus vulgaris by its characteristic crusts and ulcers, 
considered in connection with the history and associated symptoms of 
lues. 

Syphiloderma Tuberculosum. — In this eruption the lesions are usually 
multiple, flat, roundish, circumscribed, firm, light-red to dull crimson- 
red nodules, beginning commonly as macules of a lurid hue. They 
vary in size from that of a coffee-bean to that of a small nut, and involve 
the entire thickness of the skin, often also the subcutaneous tissue. 
Their surfaces are smooth, glazed, or desquamating ; and their evolu- 
tion is peculiar in that they rarely exhibit apical pustulation or ulcer- 
ative degeneration. 

The eruption is, with few exceptions, usually limited to one or more 
regions of the body, as the forehead, the chin, the nucha, the buttocks, 
and the outer surface of the thighs. It is less often disseminated than 
grouped. Occasionally there may be displayed upon the surface of the 
body but a single tubercular lesion, the recognition of its character 
usually demanding some skill on the part of the diagnostician. "When 
occurring in groups the typical circinate appearance of the syphilo- 
dermata in general may be Avanting, the patches having an irregular 
boundary ; but at times the circular, reniform, or horseshoe-shaped out- 
line is distinct, with an enclosed area of integument unaltered or the 
seat of atrophic changes. At times the lesions assume a serpiginous 
character and distribution, a condition to which has been applied the 
term 

Syphiloderma Tuberculosum Serpiginosum. — In exceptional cases ser- 
piginous and tubercular lesions are marked by secondary changes. They 
may become covered on the surface with a thin yellowish crust ; may 
lose their firmness and become soft and rather more lurid red in hue, 
from colloid, or rarely even suppurative, degeneration ; may vegetate 
luxuriantly and become the seat, especially on the scalp, of warty 
growths, smeared with a semipurulent secretion of disgusting odor 
(syphilis papillomatosa, syphiloderma framboesioides) ; or finally they 
may ulcerate, the superimposed crusts thickening in bulk, deepening 
into blackish and greenish shades, and covering typical syphilitic ulcer- 
ations, with characteristic edges, floor, base, and secretion. The degen- 
eration iij the latter case may be rapid and the destruction extensive. 
This result is, however, of rare occurrence. 

The course of the eruption is indolent, months usually elapsing 
before full evolution is accomplished. In untreated cases there is pro- 
duced a generalized and symmetrical syphiloderm. It is rare, how- 
ever, even in hospital and dispensary cases, to observe such develop- 
ment; the more superficial, generalized, and symmetrical are the 
lesions, the briefer, as a rule, is the interval between such an eruption 
and the date of infection. The later the lesions, the more are they 



636 NEW-GROWTHS. 

asymmetrical, localized, and profound in their involvement of the deep 
tissues. This syphiloderm rarely appears in the second, more often in 
the third or fourth, still more rarely in the fifth, tenth, or fifteenth year 
of the disease. 

Resolution occurs by resorption, leaving in the site of the tubercles 
according to their age, size, and contents, livid and pigmented macu- 
lations, or characteristic pigmented, atrophic, cicatriform areas. Scars 
following the ulcerative lesions are typical in color, shape, and career, 
the pigmentation of both cicatrix and areola blanching from centre to 
periphery, and leaving a delicate, dull-whitish, glazed, or slightly 
desquamating membranous new-growth ; ancient relics of this process 
resembling in appearance thin, small coin- and larger-sized, circular 
sheets of mica. 

Fig. 74. 




Ulcerative tubercular syphiloderm. (After Keyes.) 

The diagnosis is between lupus vulgaris, lepra, epithelioma, and 
psoriasis. In lupus the age of the subject, the character of any scars 
left upon the body-surface, the chronicity of the disease, and the 
absence of a history of polymorphism, will usually point to the nature 
of the disease. The tubercles of lepra are very much more indolent 
than those of syphilis, and have a characteristic oiled or varnished 
look, never the livid or dull-crimson color of syphilitic lesions. Set 
upon the forehead, the tubercles of syphilis, near the line of The hairs, 
never give the leonine aspect of those at the lower border of the fore- 
head and over the eyebrow of the leper. In epithelioma the age of 
the subject and the history of the disease are always significant. In 
the early stage of epithelioma the patient is often in a condition of 
excellent general health, while the imprint of cachexia is distinct in 
tubercular syphilis of the skin. In the later stages of epithelioma the 
ulcer with everted edges and eroded, hemorrhagic floor, " varnished " 



SYPHILIS. 



637 



with a translucent secretion, is totally different from the "punched- 
out, syphilitic ulcer with its puriform secretion and discolored crusts. 
The deep infiltration of even the desquamating tubercular syphiloderm 
will distinguish it from the circular patches of psoriasis. 

Syphiloderma Gummatosum. — The gumma is a lesion peculiar to 
syphilis ; no other disease exhibits an exactly similar feature. It is 
usually a late or so-called " tertiary " manifestation of the disease, and 
is commonly observed in the form of one or relatively few, subcuta- 
neous, strictly circumscribed, firm, w^ell-rounded, painless, and indolent 



Fig. 75. 




Syphiloma of the vulva with gummatous changes in labia and clitoris, and languettes of anus 

accompanying stricture of the rectum. 

tumors or nodules which, when first observed, are scarcely larger than 
a pea. They are then covered with an unaltered integument and are 
movable. 

Very slowly they may, when untreated, increase in size until they 
attain the dimensions of a marble, of an egg, or even of bodies of a 
considerably larger size. Sooner or later, when not resolved by treat- 
ment, they usually become attached, and the overlying skin is involved, 
showing by its livid, reddish, or purplish hue and its hypersemic 
areola that it threatens to yield. Finally, at one or at several points 
the skin is so thinned as to be incapable of further resistance, the gumma 
bursts, and a thick sanious secretion escapes, the gummy character of 



638 NEW-GROWTHS. 






which has given the lesion its name. When the inflammation has 
been active its secretion may be wholly or partially purulent, and in 
this case be furnished either by the contents of the tumor or by the 
peripheral tissue which participates in the process. Ulcers always 
result, which occasionally are fistulous in type, roundish or oval in con- 
tour, with edges clean cat, and floor purulent and extending to the 
subcutaneous tissue, tendons, aponeuroses, cartilage, or bone. Thin 
and yielding bands or bridges of undermined skin often extend be- 
tween several such solutions of continuity, and usually melt down in 
the presence of the destructive process. When repair is progressing, 
which is decidedly the rule as regards the ultimate result, granulations 
spring from the floor of the ulcer, the edges contract, and the gumma- 
tous eventually exhibits the appearance of a simple ulcer, save in the 
thinned purplish, pigmented appearance of the outlying integument. 
The scars are typical, bleaching from the centre, and they may be 
attached to periosteum or bone, though this is exceedingly rare. Con- 
sidering the depth of the process, the gumma of the skin is, as a rule, 
succeeded by less evidence of destruction at the height of the process. 
About the neck cicatrices may be linear in shape and slightly puckered. 
Upon the lower extremities and the trunk they are usually circular or 
oval. 

But one gumma may appear upon the person of a single individual, 
and when this is the case it will usually be found upon the leg. 
Half a dozen or more may at times coexist. In other cases hundreds 
form. Gummata may develop upon any part of the body, and when 
situated over the trunk of a nerve may become the seat of severe 
neuralgic pain. They are amenable to skilful treatment, and they 
may undergo resorption, leaving little or no trace of their former 
existence. 

Gummata are to be distinguished from fibrous, carcinomatous, and 
lipomatous tumors, as also from indurated and enlarged lymphatic 
ganglia. As gummata occur in very marked preponderance below 
the level of the knees, and are for the most part single or relatively 
few in- such situation, by their position alone they frequently can be 
differentiated from each of the new-growths mentioned, no one of 
which occurs by preference upon the lower extremities. As they are, 
moreover, relatively late lesions of syphilis, a history of pre-existing 
symptoms of that disease can usually be obtained. 

Erythanthema Syphiliticum. — Under this title Bronson l de- 
scribed a condition observed by himself in syphilitic patients. Upon a 
well-defined, crimson or livid, erythematous surface (face, palms, soles) 
appeared an abundant crop of pea-sized vesico-pustules, which were con- 
verted later into an exuding, whitish, elevated, diphtheroid patch. The 
multiformity of the exanthem was characteristic. In parts it suggested 
the hydroa bulleux of Bazin ; in other parts the dermatitis herpeti- 
formis of Duhring. The fluid exudation that affected the face was not 
characteristic of the evolution of the palmar and plantar lesions. 

Later, warty, papilliform lesions appeared over the face and neck, 

1 N. Y. Med. Record, September 4, 1886, p. 253. 



SYPHILIS. 639 

somewhat resembling secreting condylomata, and surmounting for the 
most part a dusky-red or erythematous surface. 

This author regarded the exanthem as primarily a syphilitic product 
but not pathologically or etiologically a true syphiloderm. Its origin 
was possibly similar to that of the angioneurotic, trophoneurotic, or 
reflex phenomena of skin-disorders in general, though possibly due to 
bacterial invasion. 

Syphilis of the Mucous Surfaces. 

The lesions of syphilis involving the mucous membranes, found 
chiefly in the mouth, but exhibited, also, in both acquired and infantile 
disease, over the nasal, aural, vaginal, anal, and balano-preputial sur- 
faces, are strictly allied to the similar symptoms in the skin. The 
differences are due to maceration of the involved surfaces, to the func- 
tions of the organs chiefly implicated, to contact, and to apposition of 
contiguous parts. 

There is, hence, every grade of disorder from hyperemia to inflam- 
mation ; and the results of the latter are both ulceration and cicatriza- 
tion, each result being subject to the special modifications due to the 
syphilitic process (gummatous deposits, infiltrations, etc.). 

In the purely hyperemic forms there is usually at the moment 
or soon after the outbreak of general syphilis a pharyngeal or a phar- 
yngo-nasal blush, spreading symmetrically or irregularly over the parts, 
accompanied often by engorgement of the tonsils, especially in persons 
previously subject to disorders of the same region due to other causes 
(catarrh, follicular tonsillitis, etc.). There is then pain on swallowing, 
and complications may arise, producing laryngeal hoarseness, cough, 
dyspnoea, aphonia, nasal discharges, crusts blocking up the passages 
(especially in inherited disease), and impeded transmission of air 
through the nares. Similar conditions may be observed about the os 
uteri, the peri-anal region, and others of the sites named above. This 
may or may not be the precursor of the severer complications — mucous 
patches, ulcers, and other symptoms of syphilis of mucous surfaces. 

Mucous Patches (Condylomata; Fr., Plaques muqueuses ; Ger., 
Schleimhautpapeln, Feigwarze) are merely syphilitic papules occurring 
in moist situations, flattened by reason of the apposition of affected 
surfaces and by contacts necessitated by the functions of the parts in- 
volved. They form upon all mucous surfaces, but are nowhere better 
studied than in the mouth, where they are the most annoying and the 
most persistent symptoms of syphilis, complicating both the early and 
the later stages of the disease. 

The patches are roundish or oval, tumid, flattened or very slightly 
depressed, pale-rosy or whitish spots, moistened with mucus, either devel- 
oping as such or resulting from hyperemic plaques of the sort described 
above, or dispersed among or upon the latter. They often resemble 
the patches produced on the mucous membrane by pencilling the latter 
with a crayon of silver nitrate. When carefully inspected, many of 
them exhibit a loosened and partially detached film of membrane, cov- 
ering the tissue, beneath which a reddish, raw-looking surface appears. 



640 NEW-GROWTHS, 

They are seen not merely upon strictly mucous surfaces, but develop 
also on the verge of the latter (mouth, anus, scrotum), and even on 
moistened cutaneous surfaces — the edges of nails in infants, and in 
persons whose hands are often macerated, between the toes, in the 
vulvo-crural angles, etc. The condyloma is by many writers described 
separately, but the older authorities were by no means in error when 
using, as appears above, the term " condyloma " for both the mucous 
patch and the flattened creamy-looking secreting papules seen often 
about the anus and the vulva of the subjects of syphilis, particularly 
those of a tender age ; for the condyloma is actually a flattened syph- 
litic papule, as is the mucous patch, the external appearances of which 
are chiefly the result of its site and surroundings. 

The secretions of these lesions are at times very offensive in odor, 
especially about the anogenital region, but also about the mouth and 
the nose (infants, the filthy, and the neglected). They may become 
fissured (edges of the tongue, tonsils, vagina), may ulcerate deeply, 
may be the seat of vegetations (papilloma, so-called " cdhiomene of 
the vulva," etc.), and, in general, may furnish a highly contagious 
secretion. It is probable that mucous lesions are more responsible for 
the transmission of contact-syphilis than are chancres. 

Mucous lesions are to be distinguished with care from simple aphthous 
patches in the mouth the result of indigestion or local disturbances ; 
also from smokers' patches (leucoplakia buccalis, " psoriasis linguae," 
leucoplasie). In external features these patches may resemble one 
another, but in only one affection, syphilis, are there other signs of 
infectious disease. The chief points of difference are : singleness, for 
the most part, of aphthous sores, and often exquisite tenderness ; mul- 
tiplicity, as a rule, of mucous patches, and much less soreness, though 
when ulcerated the soreness may be a conspicuous feature. Linear 
streaks and bands (often quite insensitive) of leucoplasie patches are 
especially found along the gums, on the lines of the inner cheek repre- 
senting contact with the approximated upper and lower teeth, and in 
the pocket posterior to the wisdom tooth. 

Scaly Patches, described by most authors separately, are not true 
mucous lesions of syphilis. They occur not rarely in syphilitic subjects 
as flattish, smooth, bluish-white or lead-white, firm, slightly indurated, 
and roundish or highly irregular plaques. They are visible on the 
dorsum of the tongue, on the mucous lining of the cheeks, and at the 
angles of the mouth, where they are situated often in part on the mucous 
surface and in part on the skin of the lip. The thickened epidermis 
is at times covered with adherent, not readily removed, scales between 
which fissures form, and the patch, at first almost insensitive, becomes 
exceedingly tender and painful. 

These patches are for the most part of the order described above, 
that is, leucoplasie, due chiefly to irritation of the mucous surfaces by 
tobacco-smoke, yet occurring in syphilitic subjects, as they are preceded 
often by typical mucous patches. They are almost exclusively seen in 
men. They are also rarely encountered in inherited syphilis. In the 
distinction sought to be made between the specific and the non-specific 
form attention is called to the occurrence in the latter class of hard, 



SYPHILIS. 641 

uneven, and considerably thickened patches, which occasionally prolif- 
erate, and which, extending to some depth, are eventually transformed 
into epitheliomatous lesions. 

Gummatous infiltrations of mucous membranes (" sclerosis of the 
tongue," of Fournier) occur in both circumscribed and diffused forms, 
superficial and deep. In the diffuse superficial forms both the mucous 
and the submucous tissues are involved in a firm thickening, best studied 
on the surface of the tongue, which then becomes to the view polished 
and smooth, at times appearing as if covered with a thin, translucent 
varnish. Patients exhibiting this condition will often describe a sub- 
jective sensation of " slipperiness." These thickenings may involve 
the deeper structures by every gradation, producing eventually lobu- 
lated masses with intervening fissures, tender, raw, and excoriated. 
The general face of the tongue is then, as a rule, covered with a par- 
ticularly foul, dirty-grayish coat, and it is occasionally notched at the 
edge with deep ulcers. At times the tongue is mottled, with patches 
of redness alternating with the yellowish white of the deposit on the 
surface of the membrane. 

The deeper gummata involve the body of the tongue, and they are 
felt as submucous, diffuse or circumscribed, dense thickenings (usually 
tolerably well defined), which soften, ulcerate, and leave exposed to 
view extensive losses of substance. The floors of these excoriations are 
deep ulcers, indurated, sloughy, and with membranous shreds over the 
surface. The fissures of the sides of the tongue described above may 
here also produce deeply ulcerated notches in the substance of this 
organ. It is surprising how greatly deformities of this class are 
relieved after cicatrization, even when considerable loss of tissue has 
resulted. 

Syphiloderma Infantile, Acquisitum et H^reditarium. 

Syphilis may be acquired by the infant child at any period after 
birth, as, for example, by immediate contagion from the nipple of the 
nurse, or mediately, as by the use of utensils smeared with a secre- 
tion capable of transmitting the disease. Such acquired infantile dis- 
ease displays, for the most part, the symptoms observed in adult years, 
except that the delicate and tender skin at this early period of life 
often exhibits the moist and secreting lesions of syphilis. The mu- 
cous patch, the pustule, and the condyloma are here more common 
than the papulo-squamous symptoms of the adult. Some influence is 
also exerted upon the disease by the dress, habits of life, and mode of 
obtaining nutriment, which are conditioned upon the helplessness of 
the young child. In this way the soiled napkin over the anogenital 
region, the warm covering of, and free diaphoresis from, the general 
surface of the skin, and the frequent contacts of the lips with the 
nipple, suffice to determine in special regions particular local expres- 
sions of the constitutional vice. The acquired is much less grave in 
character and portent than the inherited form of the disease. 

Hereditary syphilis, which may be displayed first in infancy or in 
early adult years, is always strictly transmitted by inheritance from one 

41 



642 NEW-GROWTHS. 

or both parents. The consideration of the disease in these pages being 
limited to its cutaneous manifestations, it is first to be noted that the 
infected foetus may prematurely be expelled dead-born with cutaneous 
symptoms displayed upon its body-surface. Over 90 per cent, of 
the products of conception affected with inherited syphilis perish in 
abortions. 

This condition generally argues in favor either of intense syphilis 
in one or both progenitors, or, more commonly, of relatively recent 
infection of both. Under these circumstances there are usually evi- 
dences of the death of the foetus at some date prior to its expulsion, 
the skin being macerated and the epidermis raised from the corium in 
few or many bullous lesions, beneath which the derma exhibits a livid 
reddish or a purplish hue. 

When the infant is born with a clean skin it may be shrivelled and 
emaciated, or be fat and present the appearance of sound health. 
Soon after birth, however, cutaneous manifestations appear, usually 
not before the conclusion of the first month, more commonly during 
the second, rarely after the third and the fourth. The earlier the 
date of such explosion the more intense, as a rule, is the evidence of 
the disorder. The first symptoms displayed are significant of visceral 
involvement, and are, in brief, those of marasmus. Emaciation pro- 
gresses rapidly ; the skin seems stretched unnaturally over the facial 
bones ; the expression is that of physical distress ; the cry becomes a 
fretful moan ; the integument loses entirely the rosy hue of the healthy 
infant, and acquires instead a sallow or muddy tint ; and very peculiar 
wrinkles or puckered lines radiate from the angles of the lips. Few 
observers have failed to notice the resemblance which then exists 
between the faces of these emaciated little creatures and those of the 
aged of both sexes. 

In this complexus of symptoms, however, there is absolutely nothing 
characteristic of syphilis as distinguished from other wasting diseases 
of infancy. Chronic tubercular meningitis and the gastro-intestinal 
disorders of infancy in their extreme expression furnish a precisely 
similar picture. This is natural enough, since all depend alike upon a 
similar cause, failure of proper performance of function on the part of 
the viscera in consequence of morbid changes. 

The coryza of the syphilitic infant, however, is soon declared, and 
speedily gives a clue to the nature of the morbid process. The dis- 
charge from the nares (at first serous, later purulent) desiccates suffi- 
ciently to obstruct the nasal passages or, in consequence of the tumid 
condition of the membrane lining the passages, is prevented from 
escaping. Often this discharge is furnished by a specific rhinitis chiefly 
invading the Schneiderian membrane. At times crusts accumulate 
externally about the nasal orifices, and they are seen to be similar to 
those which are prone to form also at the angles of the mouth. In this 
way the characteristic " snuffles " of the syphilitic infant are induced, 
in consequence of which it is obliged when nursing to release the 
nipple from its mouth in order to respire, an act often accompanied by 
a hoarse cry. The breathing of the syphilitic infant, even when 
asleep, or awake and . undisturbed, is often sufficient to arouse a sus- 



SYPHILIS. 643 

picion as to the nature of the disease from which it is suffering. The 
mouth, the larynx, the vulva, and the anus are often the seat of similar 
lesions, the development of which into an obstructive tumefaction 
secreting more or less profusely, or into moist condylomata, will largely 
depend upon the seat and surroundings of the lesion. 

The cutaneous symptoms of inherited syphilis are macular, papular, 
pustular, bullous, or furuncular, two or more of them being at times 
commingled, attesting thus the identity of the disease with the poly- 
morphic acquired forms of maturer years. Macules early appear upon 
the trunk, the face, and the extremities, usually of a livid reddish hue, 
commingled with papules, and indeed often occur as the first mani- 
festation of the papules. They are irregular as to shape, and though 
occasionally pinkish, discrete, circinate, and coffee-bean-sized, often 
produce a diffuse, coppery-red or violaceous, glazed, or moist and 
secreting surface, affecting an entire region, as the neck, the trunk, or 
the thighs and the genitalia. Deep excoriations and even fissures 
occasionally form in these extensive patches, and the secretions may 
incrust them irregularly, the general aspect of the patch somewhat sug- 
gesting an eczematous condition, yet remarkably differing from it in color. 

In hereditary as in acquired syphilis the type of all the eruptive 
symptoms is to be sought in the papules which may spring from the 
macules described above, and develop into pustules, bullae, or condy- 
lomata; and, in the former case, dull-red or violaceous papules of 
lenticular size occur either in asymmetrical or symmetrical arrange- 
ment, being discrete or agglomerated in patches of infiltration. These 
papules may, especially upon the buttocks, scale at the apex ; or, par- 
ticularly upon the palms and soles, may constitute by fusion a thickened 
desquamating epidermal patch ; or, commonly about the anogenital 
region, the interdigital spaces, the axilla?, and face, may become moist 
and secrete a puriform mucus. By vegetation or by hypertrophy they 
develop into flat or fissured condylomata, smeared with an offensive, 
yellowish or yellowish-white discharge ; and vary in size from that of a 
small coin to a lesion a centimetre or more in diameter, with correspond- 
ing variation in the degree of their elevation from the affected surface. 
Condylomata may be few or numerous. Sometimes a child will appear 
to be well-nigh covered with large, moist, secreting papules. Papulo- 
condylomata may deeply ulcerate and crust. It should be remembered, 
in studying these symptoms, that they are those of a cachectic infant 
affected with a grave disease. Death often interrupts the sequence of 
the manifestations above described. This event is usually preceded 
by signs of apparent amelioration, shrinkage of hypertrophic growths, 
and decoloration of hypersemic lesions and patches. Of the other 
cutaneous symptoms of hereditary syphilis, vesicles are the rarest ; the 
smaller, occasionally seen, have a conical apex with serous contents, are 
closely set together about the lips, and spring from a violaceous infil- 
trated patch. The resulting crusts never have the reddish-yellow tint 
of those observed in eczema, nor, after rupture, are they followed by 
serous oozing from a wounded epidermis. The larger lesions of this 
sort are usually transformations of papules which rapidly assume a 
pustular phase. 



644 NEW-GROWTHS. 

Pustular eruptions, in this form of syphilis, may be discrete or be 
confluent, localized or generalized. They are particularly prone to 
occur in groups about the mucous outlets, with maculo-papular lesions 
developed elsewhere, and they may result in ulceration, often after 
development into bullae with pustular or sanious contents. The 
resulting crusts are bulky and dark colored, and, especially upon the 
face, disfiguring. The subjective sensations are insignificant, since 
the child does not attempt to tear the affected surface as in pustular 
eczema. The cachectic condition of the little patient is usually pro- 
nounced when these lesions are large and numerous. They may be 
seen in typical development by the side of the nail, occasionally involv- 
ing the matrix, and producing in this situation considerable swelling of 
the digit, with an ulcerative sequel which commonly results in distor- 
tion or an ultimate loss of the nail-substance. Onychia, however, may 
result from perverted nutrition of the part, with increase in the fria- 
bility of the nail-substance, loss of lustre, assumption of a dirty-grayish 
hue, and phalangeal oedema. These changes are analogous to those 
resulting in loss of the hair where the follicles have been improperly 
nourished. 

The furuncles which form in other cases are either exaggerated 
manifestations of the same pyogenic tendency in the skin of the infant, 
a complication common to syphilitic and other cachectic conditions in 
young children, or are the result of infection with pus-cocci, a more 
frequent cause. These furuncles may be few or be numerous, and they 
are chiefly characterized by their indolence, the absence of laudable 
pus in their contents, the ulcerative condition left after their evacua- 
tion, and the bluish or purplish condition of the integument which sur- 
rounds their edges. 

Bullae in hereditary syphilis are early or late manifestations of the 
disease, and they may be represented by a single lesion on the palms 
or soles (the site of their predilection), or they may constitute a sym- 
metrical generalized efflorescence. Bullae should be regarded as evi- 
dences of a grave form of the disease, being often the precursors of a 
fatal issue, as indicating a feeble resistance on the part of the epidermis 
to the fluid exudate furnished from the corium beneath. In severe 
cases the bullae are ill developed, and the integument will be seen to be 
marked here and there by small coin-sized and larger disks or plaques 
of macerated epidermis, separated from the derma by a thin film of 
serous, sanious, or purulent fluid, in quantity insufficient to raise the 
roof above the general level of the integument. When fully developed 
they may be conical, rounded, flat, or flaccid, and be surrounded by an 
infiltrated border of dark-reddish or violaceous hue. Their color varies 
with the color of their contents. Their subsequent career is concluded 
by shallow or by deep ulceration, the base of each bulla secreting a 
sanious discharge. Crusts may form if the patient survives. A fatal 
termination of the disease is usually announced by flattening or collapse 
of the blebs. The lesions may be commingled with pustules, maculo- 
papules, condylomata, and mucous patches of the anus, the mouth, and 
the nares; but they are somewhat different from the other lesions 
described in that thfey may constitute a uniform efflorescence, no other 






SYPHILIS. 645 

cutaneous symptoms being manifested. The uniformity is due to the 
fact that bullae represent the state of feeblest resistance in the epidermis, 
the fluid exudate of exceedingly low grade mechanically separating the 
rete from the tissues beneath. 

Tubercles and subcutaneous gummata may develop in hereditary 
syphilis, but only as late manifestations of the disease, one or more 
years elapsing before their appearance. Their behavior is scarcely dif- 
ferent from that of those observed in the acquired forms, although the 
destruction wrought by their degeneration in very late manifestations 
may be of the most intractable type. Usually there is a history of 
preceding parental or inherited disease, and coincident symptoms or 
sequels of such disease, in altered teeth (as described by Hutchinson), 
in an ancient keratitis, or in a hopeless form of surdity. 

Mucous patches are very constant symptoms of the disease, and they 
represent papules of the mucous membrane that diifer from those seen 
in the skin only because they are moistened, macerated, and flattened 
by juxtaposition of neighboring tissues. They are surrounded usually 
by a lurid halo, and they may have the pearly whiteness always seen 
when the epidermis of mucous membrane is wholly or partly detached 
from the corium; or they may lose this protecting disk in shreds or 
patches, and show, beneath, an engorged or ulcerated and secreting 
tissue. They may be isolated or be broadly confluent, and be oval, 
circular, or decidedly linear in shape, the last-named appearance being 
characteristic of patches existing at the angles of the mouth. Mucous 
patches are to be recognized as distinct from both the parasitic and the 
non-parasitic forms of simple stomatitis or thrush, the parasitic form 
being due to the presence of the o'idium albicans. In both of the non- 
syphilitic disorders the mouth of the child is very generally, uniformly, 
and symmetrically involved, the circumscribed patches being distinctly 
discrete and resembling in color soft whitish or yellowish flocculi of 
curdled milk. 

The diagnosis is always greatly aided by noticing the well-nigh con- 
stant occurrence of patches at the angles of the mouth, which has also 
the seamed and puckered appearance described above. Snuffles, syph- 
ilodermata, and marked cachexia, when established, leave little doubt as 
to the nature of the malady. 

The future of the infant affected with hereditary syphilis is not 
always as dark as might be gathered from what has preceded. In 
this, as in the acquired, form of the disease benignancy may be in 
rare cases a conspicuous feature of the entire process. The evolu- 
tion of the disease may be tardy; its symptoms be few and unimpor- 
tant; its amenability to judicious treatment speedily be demonstrated. 
1 Still, the fact remains that the disease when inherited is far graver than 
I when acquired, the victim of inheritance entering the world with its 
j viscera and bones subject to profound pathologic alterations. Atten- 
tion has been directed to the important fact of the frequency with which 
the syphilitic product of conception perishes. 

Etiology. — Syphilis, in the course of which appear the syphilo- 
dermata, is produced by either accidental or intentional infection, or 



646 NEW-GROWTHS. 

as a result of heredity. In all cases it is believed that the contagiuni, 
which reaches the blood through the medium of the lymphatics, 
is effective by reason of a virus charged with a pleomorphous but 
as yet undemonstrated bacillus. The physiological secretions of the 
infected uncontaminated with pathological products are believed to be 
incapable of acting as virus-carriers, but, especially in the recently 
infected, such contamination is of frequent occurrence, and is generally 
effective in the transmission of the malady to persons not immunized 
by previous attacks of the disease. 

The methods of transmission may be immediate, as in sexual con- 
gress, in kissing, and in nursing at the nipple, by which act the child 
may infect the nurse with the secretion of the mucous patches in its 
mouth ; or it may, instead, receive the disease from the excoriations on the 
breast of the nurse. The disorder may also result through the medium 
of utensils charged with an infectious secretion, such as the needles of 
the tattooer wet with saliva commingled with diseased mucus, or the 
lancet of the vaccinator covered with an intoxicated blood. Generally 
it may be said that all the discharging and moist syphilodermata are 
sources of danger to a sound individual, both in the acquired and 
the inherited forms of the disease. 

By these and other similar methods persons of both sexes and all 
ages may become infected. 

However begotten, the syphilodermata are yet not excluded from 
subjection to the long list of external irritants which may in turn 
annoy the skin. The influence of a hot bath, or the excitement and 
perspiration of the dance, will often invite to the surface a macular 
syphilide which might otherwise be less fully developed ; friction, as 
by the hatband over the forehead, the cuff at the wrist, and the shoe 
upon the foot, demonstrates its influence by daily examples of deter- 
mination of the morbid process to special localities. In the trades 
the hands of the syphilitic laborer betray unmistakable evidences of 
the irritative effect of harsh contacts ; the same may be said of filth, 
such as the feces on the napkin of an infant that frequently provoke 
condylomata in the anal region. It is a mistake to suppose that syph- 
ilis, and syphilis only, is responsible for the exanthemata of that dis- 
ease in all shades, grades, and situations. Soap and water are as effi- 
cient in preserving the skin of the syphilitic as of the sound subject ; 
and the infected tobacco-chewer pays a price for his nauseous habit. 
Poverty, misery, and wilful neglect or ignorance of the laws of hygiene, 
are responsible for a long and lengthening list of the complications of 
the disease. 

Pathology. — Lustgarten, Doutrelepont, and others have described 
a bacillus found in chancres and in the later syphilodermata. Von 
Niessen, of Wiesbaden, also has cultivated an organism which is 
claimed to be common to all syphilitic subjects, and is said by its dis- 
coverer to be allied to the ray-fungus. The micro-organism is inva- 
riably intracellular and pleomorphous. Pathological results were 
obtained with it after inoculation of apes, pigs, and rabbits ; and it is 
claimed that signs of inherited lues were exhibited in a second gener- 
ation of the infected animals. The pathogenic value, however, of these 



SYPHILIS. 647 

micro-organisms has not been settled definitely. Syphilis is unques- 
tionably an infectious disease, but the exact nature of its infecting 
virus is, as yet, undetermined. The agent which produces chancre is 
undoubtedly present in many of the syphilodermata, while its toxins 
circulating in the blood are certainly the immediate cause of other 
lesions. Pustules in this disease in most instances are due to secondary 
infection, while many of the crusted, scaling, and other unusual 
syphilides are the result of coexistence with syphilis of seborrheal 
eczema or other inflammatory dermatoses. 

While the histological changes in syphilis cannot be considered 
pathognomonic, practically all the lesions, including chancre, show the 
same structure and processes, varying somewhat in extent, intensity, 
and in minor features, due to the circumstances of location, state of 
nutrition of the tissues, and the virulence of the infecting virus. The 
processes are always chronic in career. There are always hyperemia 
and more or less dense infiltration, chiefly about the vessels. Herzog * 
and Bieder agree that the vascular changes in syphilis chiefly concern 
the veins and lymphatics, the arteries being relatively free ; and that 
the vascular infection proceeds through the lymphatics from the peri- 
vascular lymph-spaces. The inferiority of the veins in point of 
resistance is supposed to explain the difference in susceptibility of the 
venous and arterial systems. After a general outbreak, either with or 
without antisyphilitic treatment, hematogenous immunity is secured for 
the time being. 

The cells of the syphilitic new-growth are lymphoid in type. 
There is usually endothelial proliferation. In the solid lesions (papu- 
lar, tubercular, and gummatous) the microscopical appearances are 
practically those of tuberculosis, including the presence of giant-cells. 
The neoplasm is not capable of organization, but undergoes involution 
either by fatty degeneration and absorption of the cells or by necrosis 
and ulceration. According to Jullien, the three characteristic features 
of all syphilides are the cell-infiltration, the inevitable destruction of 
this infiltrate the cells of which are incapable of organization, and the 
centrifugal development and retrogression of the neoplasm. 

In the macular syphilide the process is superficial and circumscribed. 
There may be simply hyperemia, stasis, and effusion of serum with 
slight infiltration about the vessels of the papillary and subpapillary 
layers. These vessels are dilated, and show endothelial and perithelia! 
proliferation. There is often a periglandular and perifollicular infiltra- 
tion of lymphoid cells, and the coil-glands not infrequently show a 
swollen epithelium. In the urticarial type of macule both the epi- 
dermis and the upper part of the cutis may show oedema. In the older 
and thickened macules the structure gradually approaches that of the 
papule. 

In the several forms of the papular syphilide the cell-infiltration is 
pronounced in the papillary layer and about the vessels, but extends 
also to the deeper portions of the cutis. There is more dense peri- 
follicular and perivascular infiltration than in the macule. A few 
epithelioid and young connective-tissue cells are seen, as also occasional 

1 Brit. Jour, of Derm., June, 1899. 



648 NEW-GROWTHS. 

typical giant-cells. Unna describes the new-growth as made up chiefly 
of plasma-cells of different sizes. The papular syphilide exhibits a 
larger number of incomplete giant-cells, a different arrangement of the 
plasma-cells, and more spindle-cells, together with a better preserva- 
tion of the fibrous tissue along the lymphatics, than are seen in lupus. 
The firmness of the papule is due to a decided increase in fibrous tissue 
occurring with the cellular growth. The normal structure of the 
tissues and the dividing-line between the cutis and epidermis may be 
effaced by the excessive multiplication and infiltration of cells. Dila- 
tation of bloodvessels with endothelial and perithelia! proliferation 
occurs. The coil-glands show swollen epithelium, which may multiply 
sufficiently to block the canal or even to obliterate it. 

The infiltration is often most marked about the hair-follicles, and 
may penetrate the root-sheaths, sometimes destroying the hair-papillae 
and sebaceous glands. There is frequently a deposit of pigment in the 
basal layer of the rete, and sometimes in the corium. The connective 
tissue is rarely involved, and in the majority of papular syphilides the 
infiltrate is absorbed and leaves no scar. Involution of the deeper and 
more persistent papules, however, may be followed by atrophic scars. 
The epidermis is involved secondarily, and may be thickened and 
exfoliated or thinned and atrophied. On the palms and soles the 
papules are broad and flat, due to mechanical pressure of the natu- 
rally thick and firm epidermis that is closely attached to the deeper 
tissues. Here, and occasionally in other parts of the body, there may 
be a persistent thickening and exfoliation, due probably to a secondary 
inflammatory process, for months or years after all traces of the origi- 
nal cell-infiltration have disappeared. In the anal, genital, and other 
regions where the papules are subjected to the influence of warmth, 
moisture, and friction, large, flat condylomata may develop in which 
the original histological structure of the papule may be largely obscured 
by the secondary and extensive hypertrophy of the rete, which sends 
broad processes deeply down between the papillae, though over the 
apices of the latter it may be thinned. CEdema of both corium and 
rete with dilatation of lymph-spaces and leucocytic infiltration is 
usually pronounced. 

Moist lesions (vesicles, pustules, bullae) are of exceptional occurrence 
in syphilis, being seen chiefly in the very young, in the very old, in 
cachectic subjects, or as the result of accidental and secondary infec- 
tion. These moist lesions form, as a rule, at the apices of the papules, 
and in some cases are caused apparently by an unusual intensity and 
rapidity of the process. Destruction of the cells in the centre of a 
papule may result in a pustule or superficial ulcer. The coexistence 
of seborrhoea in some of its phases is responsible for the crusting of 
many of the papular and tubercular syphilides. 

The tubercular syphiloderm is practically identical 'in structure 
with the papule, but is larger, and is seated deeper within the derma. 
The connective-tissue hypertrophy is greater proportionately than in the 
papule, the fibres of the papillae being much thickened, the blood-vessels 
and lymph-vessels greatly dilated and their walls hypertrophied. As 
in the papule, the epidermis is secondarily involved, and atrophic 



SYPHILIS. 649 

changes are of frequent occurrence. The tubercular syphiloderm is 
slower of evolution and more persistent than the papule, hence the 
mere mechanical pressure of the neoplasm frequently causes destruc- 
tion and atrophy of the normal tissue, and the involution of the 
tubercle in such cases is followed by an atrophic scar. Necrosis of 
the cells in the centre of the tubercle may result in the formation of a 
small ulcer. Peripheral extension with coincident degeneration and 
absorption or necrosis and ulceration of the central portion may occur, 
as in all syphilitic processes. The neoplasm is commonly circum- 
scribed, but may be diffuse. 

The gumma corresponds closely to the tubercle in structure and in 
career ; but is larger, and is seated chiefly in the subcutaneous tissue, 
involving the skin secondarily. 

Diagnosis. — According to Justus, a diagnostic test of syphilis 
is the sudden decrease in haemoglobin which immediately follows 
the inunction or injection (not the ingestion) of mercury in full 
doses. 

The syphilodermata are to be distinguished from all other cutaneous 
eruptions by their general characteristics and by the features peculiar 
to each lesion. It must not be forgotten, however, that these lesions 
are not essentially different in character from all others, but are to be 
recognized with ease or with difficulty according as they do or do not 
betray the syphilitic expression. No one, however expert in diagnosis, 
can always trust himself in a doubtful case to recognize these special 
features by a study of the eruption only, at a given moment of time. 
Neither in respect to color, form, size, situation, disposition, or other 
peculiarity do the syphilodermata exhibit an absolute difference from 
non-syphilitic affections of the skin. It is, therefore, requisite in every 
case to investigate in the fullest manner the history of the disease, of 
all prior skin-lesions, of a primary sclerosis (when this can be obtained), 
of adenopathy, miscarriages, abortions, and disorders affecting other or- 
gans of the body, as the bones, the viscera, the organs of sense, and the 
mucous surfaces. Often a single extra-cutaneous fact will be a valuable 
aid in establishing the diagnosis of syphilis. An " eczematous " infant 
with snuffles and a hoarse cry has been treated in vain by many a phy- 
sician, otherwise capable of making a diagnosis, who might have been 
given a clue to the nature of the disease from which the child was 
suffering if he had taken the pains to inspect the anus and question the 
father in private. 

Every syphilitic patient with a disease of the skin does not neces- 
sarily exhibit syphilodermata. The course of the disease in many cases 
is so protracted that patients have ample opportunities to contract other 
disorders, and their number is larger than is commonly supposed. 
They suffer most often from the medicamentous eruptions, especially 
those induced by the ingestion of potassium iodide (cf. the chapter on 
Dermatitis Medicamentosa : Drug-eruptions from Salts of Iodine) ; they 
are, like other men and women, bitten by bugs and lice ; and they 
suffer from eczema, acne, psoriasis, and other non-venereal disorders. 
This common susceptibility is less true possibly of the innocent victims 
of the disease than of those guilty of sexual excesses in and out of the 



650 NEW-GROWTHS. 

married state, many of the unmarried leading the most disordered lives, 
and exposing themselves to the ordinary causes of disease to a degree 
not noted in other persons. 

It is always necessary, therefore, in making a diagnosis in a case 
supposed to be syphilitic, first, to determine ab origine the fact of 
syphilis; and, if that fact cannot indubitably be ascertained, to be 
careful that the statements of the patient are not allowed to bias the 
judgment in pronouncing upon any eruption present; second, suppos- 
ing that such a fact is established by clinical proofs without reserve, 
to decide whether the eruption present is produced by the existing 
syphilis or some other externally or internally operating cause ; and if 
this last be determined, to be careful in eliminating the syphilitic influ- 
ence from its operation. 

Ignored syphilis is usually severe ; but it is without avail that dis- 
orders of a different character are treated by the methods useful in 
syphilis. Thousands are annually thus mistreated who might have 
been spared such a calamity. The frequent occurrence, after a suspi- 
cious exposure, of a balanitis, of an attack of progenital herpes, of 
uninfected excoriations, of blennorrhagic discharges, and even the 
appearance of molluscous tumors, warts, or parasitic cutaneous dis- 
orders upon the genital region, is a source of alarm and of fruitful 
error to the many rather than to the few. 

The diagnostician none the less must ever be on the alert to recog- 
nize the symptoms of the disease in those who least suspect it. Thus, 
married women complaining of a " humor of the blood," men who have 
been "overheated and broken out with a rash," and a long list of 
patients exhibiting upon their persons the symptoms of " salt rheum," 
" tetter," "scrofulous ulcers," and "erysipelas" are those whose speedy 
relief will depend upon the skill of the practitioner in recognizing 
the precise nature of the malady. 

The diagnosis of syphilitic lesions of the skin is a matter of the very 
greatest importance, inasmuch as the health, comfort, mental happiness, 
and domestic relations of thousands of men and women annually depend 
upon it alone. An error in either direction may involve the most 
serious consequences to both physician and patient. He is but poorly 
qualified to discharge the important duties of a general practitioner of 
medicine who has not carefully trained himself to establish the truth 
in these cases, irrespective of the diagnosis of the patient and of all 
others who may have been consulted. 

Treatment. — The syphilodermata are to be treated by topical 
applications intended to hasten their disappearance or involution ; but 
as local manifestations of a constitutional disease, their management is 
largely that which looks to the relief of the latter. 

The treatment of syphilis, in the pages which follow, is described 
in outline, so far as it relates to the relief of cutaneous lesions and of 
the systemic condition. The important modifications of therapy that 
are required in the management of syphilis of the osseous and the 
nervous systems, of the respiratory, gastro-intestinal, and other organs, 
it is scarcely necessary to remark, are fully described in the standard 
treatises specially devoted to this subject. Among them may be named, 



SYPHILIS. 651 

as of American authorship, the works of Taylor/ of Morrow, 2 of E. L. 
Keyes, 3 of Hyde and Montgomery/ of White and Martin, 5 and of 
Bangs and others. 6 Of those more or less recently published abroad 
may be named the standard treatises of Jullien, 7 of Fournier, 8 of Diday 
and Doyon, 9 of Mauriac, 10 of Neumann, 11 and of Lang. 12 

The first and often the most important consideration for the prac- 
titioner who is in face of a syphilitic patient is the care of that patient's 
general health. Simple and natural as it may be to set down such an 
injunction in this connection, its importance rests upon the fact that it 
is too often neglected. Patient and physician respectively are often 
hurried into the precipitate ordering and swallowing of specific drugs 
without regard to other as important details. 

It is well to hand to the patient, at the outset of all treatment for 
syphilis, a slip of paper on which are printed in concise and simple 
terms a set of rules to be observed during the continuance of the dis- 
ease. For physicians who do not take similar precautions it is advisa- 
able to enter rather fully into the explanation of certain details which 
the patient should be made to understand. 

He or she, if an adult, should, as a rule, be informed of the serious 
nature of the disease recognized, since every infected patient has an 
interest in knowing this fact, and its important bearing upon his or her 
relations to the uninfected. To every such patient, with the assurance 
that the disease is often benign and productive of little discomfort and 
in any case is curable, it should be stated that the affection is contagi- 
ous and capable of transmission to sound persons by physical contacts 
of various characters. The patient should be instructed as to the 
nutritious character of the diet he should select, and should be informed 
that an increase in body-weight while subjected to treatment is de- 
cidedly favorable in the matter of prognosis ; that the starving and 
sweating processes so highly esteemed by the charlatan and the advo- 
cate of the virtues of the waters of certain resorts are relics of antiquity, 
as useless in fact as they are frequent sources of peril. 

The bathing of the body is a matter of importance. Hot, Turkish, 
and Russian baths, as a rule, are to be interdicted, inasmuch as they 
tend to invite cutaneous hyperemia, and thus to favor the occurrence 
of eruptions. Cool or tepid baths are to be employed sufficiently often 

1 The Pathology and Treatment of Venereal Diseases. Philadelphia, 1900. 

2 System of Genito-urinary Diseases, Syphilis, and Dermatology. New York, 1893 
(3 vols.). 

3 Surgical Diseases of the Genito-urinary Organs, including Syphilis. New York, 
1888. 

4 Syphilis and the Venereal Diseases (2d edition). Philadelphia, 1900. 

5 Genito-urinary Surgery and the Venereal Diseases. Philadelphia, 1897. 

6 American Text-book of Genito-urinary Diseases, Syphilis, and Diseases of the 
Skin. Philadelphia, 1898. 

7 Traite pratique des Maladies veneriennes. Paris, 1886. 

8 Lecons sur la Syphilis, etc. Paris, 1873. La Syph. Hered. tard., 1886. Traite- 
ment de la Syphilis. Paris, 1895. Les Chancres extra-genitaux. Paris, 1897. Traite 
de la Syphilis, tome i. Paris, 1898-99. 

9 Therapeutique des Maladies veneriennes. Paris, 1876. 

10 Lecons sur les Malad. vener. Paris, 1883 and 1895. 

11 Syphilis. Vienna, 1896. 

12 Vorlesung. uber Pathol, u. Therap. d. Syphilis. Wiesbaden, 1896. 



652 NEW-GROWTHS. 

for the purpose of cleanliness, and by the sponge rather than by immer- 
sion. Dry friction daily of the surface of the body may be ordered 
with advantage where the skin is still sound. The teeth, the mouth, 
and the gums require constant care. The use of the tooth-brush with 
cool water twice daily is a matter of importance, and the brushing 
should be preceded for a time, when the gums at the outset are in a 
tender, fungous, or hemorrhagic state, by gentle friction of the teeth 
with the finger, covered by a handkerchief dipped in a weak spirit-and- 
water lotion, to which tincture of cinchona and of myrrh may be added 
in any desired proportion. Tobacco in every form is decidedly inju- 
rious. Often the patient should be sent to a competent dentist for the 
extraction or the filling of carious teeth, and for the removal by the file 
or the dental engine of all sharp, projecting edges. 

Malt liquors, wines, and spirits should be employed solely under the 
explicit direction of the physician. They are exceedingly useful in 
debilitated subjects of a certain class, and need not be prohibited in 
toto to those long habituated to their use. At the same time, an im- 
proper use of these stimulants is in the highest degree harmful. When 
employed at all, they should be restricted rigidly to the dining-table 
and the hours of meals. 

A compliance with the laws of hygiene is even more requisite for 
the syphilitic than the non-infected. Fresh air, social amusements, 
exercise, the regular routine of business life, or, when this has proved 
exhausting, the recreation of travel — the claims of all these need at 
times to be urged by the physician. With this the patient should be 
encouraged to free his or her mind from needless anxiety, and to avoid 
particularly the company and conversation of those similarly infected, 
whose opinions are based too often upon ignorance or upon a knowl- 
edge of half-truths. The literature of syphilis, for a similar reason, is 
to be eschewed, as a mass of patients, too many of whom purchase 
treatises on the subject, are able only imperfectly to glean the meaning 
of the authors consulted. 

It should be a rule to urge a married patient to inform the conjugal 
partner frankly of the fact of infection, for the sake of both. When 
this advice is followed much future trouble is avoided, and one of the 
obstacles to a completely favorable issue is at once set aside. Instances 
occur in which disruption of the conjugal bond results from infec- 
tion of one, but usually of both parties ; it is a striking argument, 
however, in favor of the policy here urged, that cases are rare in 
which a frank and honorable confession has been followed by sepa- 
ration. It may be added that in no one of the "confessed" cases 
has there been a subsequent infection of the innocent. The larger 
number of married patients are husbands. Recently infected young 
adults who have contracted a marriage-engagement should invariably 
claim release from such a tie for the sake of all concerned. The syphi- 
litic nurse must at once be taken from the sound nursling, and the 
child with hereditary syphilis must be suckled only by its mother, who, 
according to Colles's law, the exceptions to which are so few as to 
prove the rule, always enjoys immunity against the diseased mouth of 
her own child. 



SYPHILIS. 653 

Respecting the medicaments employed in the treatment of syphilis, 
there is no routine plan which in every case can advantageously be 
followed. In no respect do physicians so differ from each other, 
judged by the standard of professional skill, as in their ability to use 
a single remedy with success. He who has the largest armamentarium 
is not always either the best equipped or the most successful. Mercury, 
iodine, iron, and quinine are the great remedial agents in syphilis, but 
they may vainly be used by one man in the long effort to accomplish 
that which another speedily and brilliantly achieves by the use of the 
same remedies employed with, greater skill. 

Of the other substances vaunted as either advantageous or specific 
in the treatment of the disease, no one possesses any claim whatever 
to the confidence of physicians. Sarsaparilla, dulcamara, stillingia, 
guaiacum, tayuya, mezereon, and the long list of other vegetable prep- 
arations whose virtues have thus been extolled, are for the most part 
as harmless in themselves as they are ineffectual for the relief of the 
malady. 

Before proceeding, how T ever, to assume the responsibility of directing 
a course of treatment for syphilis with remedies of acknowledged value, 
the physician will do well to remember that no two cases of the disease 
are precisely alike, and that there is the widest range between the most 
benignant forms encountered in private practice and the malignant 
cases seen in hospital-wards. Some forms of the malady are so mild 
as to constitute merely an inconvenience ; others are so severe as to 
destroy life. It is an axiom in venereal disease that more patients per- 
ish annually from blennorrhagia and its results than from syphilis. 
There could be no greater error than to treat by a uniform method any 
disease exhibiting so wide a variation in severity. 

Mercury, after the assaults upon it of generations of men of admitted 
wisdom and candor, stands to-day unrivalled as a remedy for the relief 
particularly of those stages of syphilis in which the skin is involved. 
Administered with skill, it can be employed for years with immense 
advantage to the syphilitic patient, who, during a well-regulated mercu- 
rial course, should gain in weight, improve in vigor, and exhibit a 
healthy color of the skin. No competent physician of to-day employs 
it in such a manner as to induce salivation or other toxic consequences. 
Such effects of the remedy result from the carelessness or the ignorance 
of the prescriber. It should be remembered that in every discussion 
of the merits of mercury in syphilis both physicians and patients have 
been guilty of the ignorance or the folly of ascribing to the remedy the 
disastrous effect of the disease. 

Mercury may be given by the mouth, by inunction, by subcutaneous 
injection, or externally by the aid of the vapor-bath. The most popular 
method, and that productive of least inconvenience to all concerned, is 
the method by ingestion. 

Ingestion. — In this mode of treating syphilis the mild chloride, 
bichloride, bicyanide, or blue mass, of mercury may be employed effec- 
tively. These preparations, however, are rather less adapted than others 
for continued employment during long periods of time, and are open to 
the objection of either readily undergoing rearrangement into more 



654 NEW-GROWTHS. 

stable compounds of the metal, or of producing undesirable irritative 
effects. With the protiodide and the biniodide an impression can be 
produced upon the "system that can readily be proportioned to the 
exigencies arising in every case, which can be sustained during that 
" chronic medication " which Fournier declares to be requisite in every 
chronic disease, and which can be exerted without fear of immediate or 
of remote deleterious consequences. 

Treatment of syphilis by the mercurial selected for use should, as a 
rule, be begun only at the moment of evolution of constitutional symp- 
toms. The initial sclerosis of the disease is amenable to the action of 
the metal to a remarkable extent, but in a large proportion of cases the 
chancre will cicatrize, when in an ulcerative stage, without having re- 
course to general medication. Early mercurial medication may well be 
reserved for such primary lesions as are threatening in symptoms, and 
for such individuals as require or demand speedy cicatrization of their 
chancres, as, for example, those about to travel beyond the reach of med- 
ical assistance. Personal experience fully confirms the wisdom of the 
teaching which reserves specific medication until the second period of 
incubation has passed. No local or general treatment can avert either 
a mild or a severe explosion of symptoms after that period is completed. 
In experiments made to determine this question of delay there has 
been either the production of strikingly irritative effects, such as a 
marked relapse, or unusual increase in the volume of the initial sclerosis 
immediately before the evolution of the first syphilodermata, or a dis- 
tinct obstinacy in the latter to the action of the medicament employed. 

In the early stages of syphilis in adults the mercurous iodide may 
be named as one of the most trustworthy preparations. Of all classes 
of adult patients, including strong men and adult women, there are 
scarcely 2 per cent, who cannot take it, if the dose be proportioned to 
individual susceptibility. It is usually administered in pill or in tablet 
form in doses of £ (0.01), -J- (0.013), \ (0.016), or \ (0.022) of a grain, 
three times daily, combined with the extract of gentian. The dose 
may be increased gradually according to the necessities of the case, 
from J (0.032) to 3 (0.207), and even 4 (0.266) grains in the twenty- 
four hours. Many of the gelatin-coated pellets found in the market 
contain accurately divided doses of the salt. The sugar-coated pills 
of Gamier and Lamoureux, containing each 1 centigramme of the 
protiodide, are efficient and largely employed. 

Beginning with a minimum dose, this remedy is to be steadily 
exhibited, and the daily quantity consumed to be gradually increased 
until the degree of tolerance of which the patient is capable has been 
ascertained. Should the stools become frequent, pain be excited, or a 
slight effect produced upon the mouth, as indicated by a metallic taste, 
moderate increase in the quantity of saliva, or any noticeable degree of 
tenderness of the gums, the dosage is to be gradually diminished until 
these symptoms disappear. Often the withdrawal of ^ (0.033) or £ 
(0.013) of a grain daily will suffice to enable the patient to tolerate the 
quantity thus diminished. The medication is to be faithfully continued 
until the object in view is obtained, viz., relief of all symptoms of the 
disease. 



SYPHILIS. 655 

In Keyes's so-called " tonic treatment of syphilis" the dosage is 
increased only on each third or fourth day, until irritative effects are 
produced, when, after an interval of two days, the quantity taken at 
the time of the production of such effects is reduced from one-half to 
one-third. This reduced quantity is termed the " tonic dose," and is 
thereafter continued throughout the treatment in " nearly all conditions 
of health or disease." l 

It may not be proper to administer a mercurial for weeks at a time 
to all subjects of syphilis who are in apparently good health. With 
the active measures at immediate control in the vapor-bath, it is usually 
safe and not unwise to suspend temporarily specific medication of the 
patient who exhibits such amelioration of symptoms as to be free from 
external manifestations of the disease. Every syphilis has its periods 
of activity and repose. Such period of repose will well be employed 
in the administration of iron, which, as tending to relieve the distinct 
chloro-ansemia of the disease, has its claims to recognition in the list 
of "specific" remedies. No case of syphilis can be said to have been 
treated properly in which this remedy has not been given for at least a 
part of the time during which the patient was under observation. 
Ferric citrate with quinine is an excellent preparation administered at 
the meal-hours, in a small quantity of sound sherry wine ; or ferrous 
iodide may be employed in syrup, or in the pills made after the formula 
of Blancard, or in Vallet's mass. In some cases tincture of ferric 
chloride may be employed, but the physician should be careful about 
ordering an acid preparation of any kind during the interval of a 
mercurial course. There is no form of anaemia which responds more 
promptly to the chalybeates than does that produced by the syphilitic 
virus. 

The mercuric iodide may be substituted for the mercurous iodide 
when, for any reason, it is thought desirable, beginning with a minimum 
dose of -g 1 ^ grain (0.001), and increasing this gradually to -^ (0.0016), 
or rarely to -^ (0.0033), either in pill or in solution. The average 
dose of -fa (0.0016) of a grain in pill-form, administered three times 
daily, soon after eating, is tolerated by the majority of all patients of 
both sexes without consciousness of unpleasant effects. 

For those who prefer to use the more active and correspondingly 
dangerous salts of the metal, calomel may be administered in 1 or 2 
grain doses (0.066-0.133) three times daily, in combination with an 
opiate to prevent its action on the bowels, or in fa grain dose (0.0066) 
every hour. Small doses of blue mass or of gray powder may also be 
employed. The gray powder is most suitable for children and infants, 
but since the frequent discovery in the drug of the corrosive chloride, 
either as of early or of late chemical production, the gray powder is 
less esteemed. The decimal trituration of calomel with sugar of milk 
is a far more suitable compound. Corrosive sublimate, in doses of 
from fa (0.0033) to fa (0.005) of a grain is exhibited in pill-form or in 
solution, and is probably more generally employed in the treatment of 
syphilis than any other mercurial salt. The objections to its use are 

1 Amer. Jour. Med. Sci., January, 1876; Phila. Med. Times, November 25, 1882, 
p. 337. 



656 NEW-GROWTHS. 

suggested above. Though constantly employed in public charities, 
where it is furnished as a cheap and a convenient substitute for the 
more elegant preparations in the market, it is much less frequently 
ordered for syphilitic patients in private practice. When given in 
solution it produces a disagreeable metallic taste in the mouth that 
some patients can perceive after the lapse of hours. 

With many physicians of wide experience it is customary to employ 
opium, either alone or in connection with the use of mercury, for the 
relief of ulcerative or other lesions of syphilis. Sometimes it is 
employed for the purpose of relieving pain, sometimes to prevent the 
cathartic action of the metal upon the bowels, and again because it is 
supposed to possess some power of arrest over the destructive action 
of the disease. It should not, as a rule, be exhibited when by reducing 
the mercurial or exchanging the latter for a ferruginous dose the same 
result can be reached. Few syphilitic patients are in the end brought 
to the desired termination of the disorder by the use of a remedy which 
interferes with assimilation and digestion ; such a remedy is opium in 
all its forms. Temporary advantage is often gained by its employ- 
ment, but this may be more than counteracted by its ultimate effect 
upon the gastro-intestinal tract. 

Inunction. — Mercury is also satisfactorily introduced by the method 
of inunction. The metal when thus employed is readily absorbed by 
the system, and its therapeutic value is no less evident. Inunction 
should be employed in every case which admits of it, since the gastro- 
intestinal tract is thus left undisturbed, and, further, the dose of any 
needed chalybeate or of potassium iodide by the mouth can be regulated 
without increasing or diminishing the quantity of mercury in daily use. 
Mercurial ointment compounded with lanolin is best used for this pur- 
pose, but a cleanly substitute for it is provided in the oleate of mercury 
in the strength of 10, 15, or 20 per cent., and in the vasogen capsules. 
From J to 1 drachm (2.-4.) of either the ointment, the vasogen com- 
pound, or the oleate may be rubbed into the skin at night before retir- 
ing, and the part selected for inunction be cleansed by washing in the 
morning. Unna for this purpose praises the mercury-salve soaps. 
All these preparations, if continually applied to a single portion of the 
skin, are liable to produce a mild local dermatitis or an eczema, hence 
it is wise to select on successive evenings a fresh portion of integument 
for the local application, preferably that where the epidermis is rela- 
tively thin, as, for example, the flexor aspects of the joints. The 
patient can thus upon one evening anoint the inner faces of the thighs ; 
upon the next, the sides of the chest ; upon another, the loins, etc., 
taking care to avoid surfaces where an induced eczema is likely to prove 
especially annoying, such as the scrotum, the axillae, and the groins. 
The ointment in some cases may be well rubbed into the soles of the 
feet previously soaked in warm water, after which the socks or stock- 
ings may be drawn over the feet for the night. In the case of infants 
the inunction is well performed by the natural movements of the child, 
if a flannel swathing-band previously smeared with the salve be 
wrapped about its belly, so that the mercurial preparation is kept in 
contact with the skin. , Should local irritative effects be produced, these 



SYPHILIS. 657 

subside rapidly, as a rule, after a warm alkaline ablution followed with 
a bland dusting-powder. Subsequently or even before such accident in 
the case of infants or of patients having unusually sensitive skins the 
mercurial salve may be mixed with equal parts of lanolin, lard, or 
olive-oil. As some patients become disgusted with this routine, it is 
well at the onset to flavor the substance selected for inunction with 
lavender, rosemary, or bergamot. 

Too little attention has been attracted to the treatment of syphilis by 
mercurial inunction. With this fact in view the preceding paragraphs 
which describe the use of mercury by the mouth are to be understood 
as related in all cases to the employment of the metal by the skin. It 
is well to order inunction in all practicable cases ; to save the stomach 
as much as possible ; to continue with the mercurial ointment nightly, 
weekly, or less frequently, so long as there is a possibility of relapse ; and 
to adjust carefully the quantity employed to the exigencies of the case. 
In this manner patients may be relieved of all symptoms of the dis- 
ease who have not during their treatment swallowed a dose of mercury, 
and the permanency of whose relief may be tested during years of sub- 
sequent observation. 

Fumigation. — One of the most effective methods of administering 
mercury is by fumigation in the vapor-bath. It is employed by many 
experts as the sole means of exhibiting the mercurial selected for 
use, but it is, for the average patient, too inconvenient for continuous 
employment. It should regularly be ordered, first, in all cases in 
which the earliest syphilodermata are intense, generalized, and partic- 
ularly conspicuous upon the face ; second, in all obstinate cases in which 
the patients are not women nor cachectic subjects of either sex ; third, 
at the outset of treatment of many " ignored " cases in which the syph- 
ilodermata, either more or less generalized, have proceeded to uninter- 
rupted evolution ; fourth, in the severe cases of patients coming from 
the country to the city, who are able to remain but a brief time 
within reach of advantages offered in metropolitan centres. From ^ 
to 1 drachm (2.-4.) of calomel, metallic mercury, the bisulphuret, the 
black oxide, or hydrargyrum cum creta may be employed for each 
bath. It is common to order 1 scruple to 1 drachm (1.-4.) each of 
calomel and cinnabar. The patient is stripped of his clothing and 
seated in a chair, the patient and chair being completely enveloped in 
blankets, which are closely fastened at the neck of the bather. Beneath 
the chair is an alcohol lamp, surmounted by a metallic vessel containing 
water in ebullition, the hot vapor of which in a few moments induces 
copious perspiration. When this result is obtained the lamp is brought 
beneath a metal plate containing the substance to be volatilized. The 
patient remains exposed to the vapor about ten minutes after this proc- 
ess of sublimation is finished, and retires at once to bed without 
cleansing the skin, the fumigation preferably being conducted before 
the hours of sleep. In the morning a bath may be taken for the pur- 
pose of cleanliness. It is more convenient in the generation of the 
vapor in this way to make use of Henry Lee's safety fumigating- 
lamp, but the materials requisite for the production of all desired effects, 
with the exception of the alcohol lamp and the drug, can be procured 

42 



658 



NEW-GROWTHS. 



of any skilful tinsmith. In the city male patients are often sent to 
bath-houses, where the fumigation is conducted in the daytime ; and, 
as a consequence, they rarely experience unpleasant effects, such as are 
popularly associated with " taking cold " after exposure to the action 
of mercury. In most of these establishments provision is made that 
the head also can be exposed to the mercurial fumes, respiration 
being conducted through a tube in connection with pure air, a provision 
useful in certain cases of emergency ; and only " emergency cases " 
should be required to resort to fumigation of the head. 

Fig. 76. 




Lee's safety-lamp for fumigation. 

The happy effect of the mercurial vapor-bath is often marvellously 
rapid. A generalized syphiloderm may become well-nigh indistin- 
guishable upon the surface after four baths at intervals of two days 
each. With this potent agency at hand, it can be understood how 
the skilled physician can afford to watch from week to week his 
syphilitic patient taking a dose of iron internally and employing in- 
unction externally, the lesions fading slowly from the surface, all fears, 
quieted, and nutrition sustained at a high grade. In comparison with 
this combined method, the swallowing of blue mass, or of calomel and 
opium, should be regarded as a clumsy and dangerous procedure. 

Subcutaneous Injection. — The treatment of syphilis by mer- 
curial injection has largely been extended since its acceptance as a 
scientific procedure. It should never be ordered save in eases specially 
indicating its employment. With some of the other methods employed, 
injection provides for the exclusion of the medicament from the gastro- 
intestinal tract, and accomplishes the desired effect with a minimum and 



SYPHILIS. 659 

exactly mensurable dosage. The objections to its systematic employ- 
ment outside of hospitals are chiefly the need of a physician or an 
expert to administer the dose. The injection of mercury into the deep 
muscular tissue (the gluteus in its thickest part with the muscle wholly 
relaxed ; the trapezius above the upper scapular angle with equal lack 
of tension), as well as when practised more strictly hypodermatically. 
requires all antiseptic precautions both as to the point where the needle 
is inserted and as to the instrument itself. It is to be remembered 
that these injections have occasionally proved fatal (calomel, gray oil), 
and grave mischief has followed, in one or two instances from visceral 
troubles. 

This method, which was first popularized by Lewin, 1 is open to the 
serious objection, while reaping the obvious advantages, of requiring 
the aid of a physician for the administration of each dose. It is 
efficient and speedy, but will probably always find largest favor in 
the treatment of hospital patients, who are completely subject to the 
orders of their medical attendant. At the site of the injection, too, 
not rarely abscesses have formed. Corrosive sublimate, -^ (0.005) 
or \ grain (0.008), dissolved in 10 or 15 minims of distilled water 
may be injected at a time, the operation being repeated upon about 
twenty occasions. Bamberger, of Vienna, reported favorable results 
after the injection of an albuminate or a peptone of mercury, thus 
attempting to avoid the danger of localized abscesses, and insuring 
speedy absorption of the metal. All formulae, however, proposed for 
preparation of solutions of this character have proved imperfect, both 
in consequence of failure to obtain a pure metallic albuminate, and 
also from lack of permanency in the solution. Staub's formula, the 
result of experiments made by Hepp, 2 may be taken as a sample of the 
rest: 

R Hydrarg. chlorid. corros., gr. xviij ; 1[20 

Ammon. chlorid., gr. xviij ; 1 20 

Sod. chlorid., 3j ; 4 

Aq. dest., f^iv; 120 M. 

Dissolve, filter, and add the white of one egg in distilled water sufficient 

to make §iv(120.); 15 minims of the solution contain about ^ 
grain (0.005) of the sublimate. 

Other preparations employed for hypodermatic injection are as 
follows : 

Insoluble salts of mercury. Here are included calomel in an aver- 
age dose of 1 grain (.066) suspended in vaselin-oil, salt and water, or 
mucilage and water; metallic mercury, frqm 6 to 30 grains (0.40-2.); 
oleum cinereum, mercury with liquid vaselin or lanolin, 20 to 50 per 
cent., 0.05 to 0.1 at each injection; and the yellow and the black oxides 
of mercury, corrosive sublimate, mercuric cyanide, and combinations of 
these with potassium iodide and other salts. 

1 Die Behandlung der Syphilis mit Subcutaner Sublimat-injection, Berlin, 1869 ; 
also translated by Proegler and Gale, Phila., 187?. 

2 Traitement de la Syph. par les Inject, hypoderm. de Sublime. These de Paris, 
1872. 



660 NEW-GROWTHS. 

The so-called "antiseptic group" includes salicylate of mercury. 
A Pravaz syringeful is injected every third day in the gluteal region 
beneath the muscular fasciae, of the following : 



R 



Hydrarg. salicylat., 


gr. xv-xxiv ; 




1.- 


Mucil. acac, 


gr. viij ; 




533 


Aq. dest., 


f ^vss ; 


165 





M. 



In this group are also included carbolate of mercury; thymolate 
(10 per cent, suspensions in fluid paraffin); and the benzoate associated 
with sodium chloride, 2 parts, and cocaine hydrochlorate, 1 part, in 500 
of water. 

The amide group includes mercuric formamidate, 1 per cent, solu- 
tion; glycocoll of mercury, alaninate of mercury, and succinamide of 
mercury, the last two in 1 per cent, solutions. 

Beside these mercurial preparations, potassium iodide and iodoform 
have subcutaneously been injected in a few instances, it is claimed 
with advantage. 

Intravenous injections of mercury in syphilis have been practised, 
but, according to Marshall, 1 have not been shown to possess any ad- 
vantages over other methods employed. Chopping, however, 2 had sat- 
isfactory results in twenty-three days after introduction into artificially 
distended veins of 20 minims of a 1 per cent, solution of mercurous 
cyanide. 

Ptyalism, stomatitis, fetor of the breath, or a fungous condition of 
the gums with inappetence and other characteristic symptoms of the 
ill effects of mercury, including all grades of gastro-intestinal disturb- 
ance, are rarely seen in modern practice, and they should never be per- 
mitted to occur in a properly regulated mercurial course. When they 
are produced, the tongue projected from the mouth is usually tumid, 
and exhibits at its lateral borders the imprints of the inner faces of the 
molar teeth. Its surface is also covered in various degrees with a thin, 
dirty-grayish coat ; and the odor of the breath is peculiarly offensive, 
being often noticeable at a distance of several feet from the patient. 
In such cases the food should be liquid and nutritious, both hot and 
cold drinks should scrupulously be avoided, and the mouth frequently 
be cleansed with washes containing dilute liquor sodse chlorinatse, potas- 
sium chlorate, borolyptol, or a very weak solution of carbolic acid. In 
particularly severe cases, potassium chlorate may be employed to the 
extent of 1 drachm (4.) daily. The compressed tablets of this salt, 
each containing 5 grains (0.33), may be slowly dissolved in the mouth. 
The mercurial is to be suspended in all cases, and iced water is to be 
interdicted, gangrene having followed its use in a few cases. In 
milder forms tincture of myrrh and of cinchona, diluted with sweetened 
water, or honey and water, will be sufficient for local medication of 
the mouth. 

Iodine is chiefly employed in syphilis in the form of potassium 
iodide. It possesses some value, without question, in every stage of 

1 Lancet, April 1, 1899. 
. 2 Ibid, 



SYPHILIS. 661 

syphilis, and is, therefore, indiscriminately used by many practitioners. 
Its value, however, in so-called " late secondary " and " tertiary 
stages " is incontestably greater than in the earlier lesions of the dis- 
ease, and its use should largely be restricted to the particular periods 
in which these manifestations appear. Every prudent physician will 
hesitate before ordering for a disease exhibiting cutaneous lesions a 
remedy which will positively produce such lesions in the majority of 
all patients ingesting it. In this connection the reader will do well to 
consult the chapter on Dermatitis Medicamentosa, in which the various 
eruptions produced by this drug are recorded. Thoughtful men are 
beginning to inquire, in the light of the present knowledge upon this 
subject, to what extent the syphilodermata have in the past been 
aggravated or obscured by this remedy. He would indeed be bold 
who should attempt to prove that the medicamentous eruptions thus 
excited have not, in the past, figured largely in the catalogue of the 
syphilodermata. 

The value of the iodine compounds, nevertheless, properly adjusted 
to the age and other conditions of the disease, is incontestable. AVhether 
given alone or by the so-called "mixed" treatment in combination 
with mercury, or administered internally while a mercurial is intro- 
duced by the skin, or exhibited by alternation with the metal, in each 
these compounds find a special value, and may simply be indispensable. 
Potassium iodide may be given in doses of from 5 grains (0.33) to 1-2 
drachms (4.-8.), well diluted with water, three or four times daily one 
hour after eating. The larger doses should invariably be reached grad- 
ually ; they should never be employed except by special order of the 
physician, and when the patient is within easy reach of the latter; 
and they should always be ordered with the understanding that the 
patient shall diminish or suspend treatment in case of unpleasant 
results. When the remedy produces gastric distress it is often admin- 
istered in connection with pepsine, pancreatine, or taka diastase. Often 
the dosage is well tolerated when given in a glassful. of milk. 

Symptoms of iodism, other than the production of cutaneous lesions, 
such as coryza, oedema of the eyelids, and faucial irritation, are 
likely to be the result of the first few doses of iodine ingested, and 
these symptoms often bear no relation to the size of the dose. In 
certain cases, 1 or 2 grains (0.066-0.133) will be sufficient to produce 
the most disagreeable toxic effects, which, if they occur before the 
remedy be suspended, may not return with even the largest doses. In 
a few cases potassium iodide produces violent toxic effects in any dose, 
owing to exceptional idiosyncrasy. Both ammonium chloride and 
ammonium carbonate are recommended for use in combination with 
potassium iodide, as increasing its efficiency. Sodium, ammonium, and 
lithium iodides possess also, without question, some influence over the 
disease, but they are for most cases less efficacious than the potassium 
salt. Of the three iodides named, lithium iodide is apparently most 
prompt in its effects. 

Potassium iodide is employed frequently in the well-known "sirop 
de Gibert," which though first popularized in the Saint Louis Hospital, 
in Paris, has since extensively been employed in the United States. It 



662 NEW-GROWTHS. 

has slightly been modified to suit the varying tastes of many surgeons. 
It is ordered in the following formula : 



R Hydrargyri biniodid., gr. ss-ij ; 

Potass, iodid., §aj-viij ; 8-30 

Gentian, syrup, (vel ] • 

syrup, glycyrrhiz.), > aa f ^ij ; aa 60 

Aq. dest., J 

Dose. A tablespoonful in water, after eating. 



033-0.13 



M. 



The syrup of licorice disguises the taste of the drug better than most 
of the other syrups used. With the dosage carefully regulated, a few 
drops (1 to 15) may be administered with advantage to children. 

The following are indications for the use of potassium iodide either 
alone or by the so-called " mixed " method in the treatment of syphilo- 
dermata: the occurrence (1) of "late," tubercular, gummatous, or ulcer- 
ative lesions ; (2) of formidable nervous, visceral, or other non-cutane- 
ous symptoms with early or late, mild or severe syphilodermata, as, for 
example, grave ulcerations of the velum or the fauces with a sym- 
metrical macular eruption, or coincidence of a generalized pustular or a 
papular syphiloderm with hemiplegic, aphasic, ocular, or renal compli- 
cations ; (3) of early or late manifestations which either assume the so- 
called "galloping" type, being rapidly succeeded by more and more 
formidable symptoms, or which exhibit the capriciousness of the disease 
in a reversal of the usual sequence of evolution, as, for example, when 
symptoms commonly counted as " late " phenomena occur within a few 
weeks after infection and are followed by the early symmetrical rashes ; 
(4) of early or late symptoms occurring in cachectic, strumous, or other- 
wise debilitated patients. Mercury is assuredly not a tonic in tubercu- 
losis commingled with syphilis. 

Klingmuller 1 advocates in late syphilis the employment of iodipin, 
an organic combination of iodine and sesame oil. It is employed both 
internally and by. subcutaneous injection. 

The local treatment of the initial sclerosis of syphilis by complete 
excision, lauded by Auspitz, has been practised (since the date of his 
paper in 1879) by Kolliker, Zeissl, Leloir, Chadzynski, Mauriac, and 
others. 2 The result has proved conclusively that such operative inter- 
ference furnishes no bar to constitutional infection. Simultaneous 
extirpation of all lymphatic glands in the vicinity of an initial sclerosis, 
with ablation of the latter and a mass of tissue about it, have repeatedly 
proved unavailing to prevent the occurrence of systemic infection. 
Chancres should not be destroyed by caustic agents of any character, 
as the caustics are liable to induce either irritative or inflammatory 
effects which may be followed by denser induration. Ointments, as a 
rule, are also objectionable, exception being made in the case of hemor- 
rhagic lesions when the removal of an adherent dressing is followed by 
unpleasant consequences. Cleanliness with soap and water is of chief 
importance. There are few better local applications at this period of 
the disease than painting with a saturated solution in water of pyok- 

1 Berlin, klin. Woch., November 25, 1899. 

2 See Keyes'-s later communication on this subject, loc. cit. 



SYPHILIS. 663 

tanin-blue. The parts may then be dusted with a dry powder, such as 
europhen, iodol, zinc stearate, calomel, hydronaphtol, or boric acid; 
or be dressed with a piece of soft lint, saturated in pure or dilute lotio 
nigra, or, even better, a spirit-lotion containing tannin and carbolic or 
boric acid. Opiated washes or iodoform (which is an anaesthetic for 
many ulcerative surfaces) may be requisite in painful and ulcerative 
lesions. When a phagedenic tendency is shown (an exceedingly rare 
complication of syphilitic chancres) deep cauterization may be required, 
and the subsequent local employment of solutions of potassic perman- 
ganate, from 2 to 10 grains (0.133-0.666) to the ounce (30.) of water. 

When a primary venereal sore of any character (the initial scle- 
rosis of syphilis or the chancroid) becomes phagedenic or gangrenous, 
or, even in the absence of both of these calamities, extends rapidly 
in depth or superficial area, cauterization should not be practised. 
The most effectual treatment of these complications in the genital 
region is by the employment of the continuous hot water-bath, aided 
by antisepsis. The patient remains seated in the bath (the water being 
of the temperature most grateful to the affected surface and with great 
care maintained at that degree of heat) throughout the day, or, in 
formidable emergencies, if carefully watched, by day and night. The 
bath is left by the patient only for the purpose of evacuating the bladder 
or the rectum. Granulation and repair gradually take place. When- 
ever the patient leaves the water the parts are dusted with iodoform or 
with iodol. By this invaluable means, in both hospital and private 
practice, cicatrization of extensive ulcers which reach from the genital 
half-way to the pubic region may be secured. 

Local treatment of the syphiloclermata may be demanded either by 
reason of their appearance on exposed surfaces, as on the face and the 
hands, or by reason of their obstinacy or threatening character, as 
when they are rapidly ulcerating. Macular and papular lesions of 
the face may be treated by local applications of mercury : 5 per cent, 
oleate ; mercurial ointment, 1 to 2 drachms (4.-8.) to the ounce (30.) 
of cold-cream salve or of vaselin; red oxide, from 2 to 4 grains (0.133- 
0.266) to the ounce (30.) ; or ammonium chloride, ^ to 1 scruple (0.666- 
1.33) to the ounce (30.) of ointment. Lotions of bichloride, 1 to 2 
grains (0.066-0.133) to the ounce (30.) of cologne, are also efficient. 
These preparations will each be found much more valuable if used at 
night before retiring, and left upon the lesions during the hours of sleep, 
and each is well preceded by hot bathing of the surface for several min- 
utes, as in the preparatory treatment of acne papulosa. The sulphur 
preparations employed for the relief of that disease will at times be 
found useful also in the local treatment of the syphilodermata. 

Hot ablution is particularly useful in the treatment of the scaling 
and frequently fissured lesions of the palms and soles, the pain of 
the local symptoms in severe cases being greatly alleviated by this 
treatment. After the epidermis in these parts has been well macerated, 
the hands or the feet should thoroughly be dried, and the mercurial, 
tarry, or other salve be well rubbed in. The medicated mulls and 
plasters are here of value. A glove or a stocking shctuld then be 
drawn over the part. 



664 NEW-GROWTHS. 

Secreting condylomata, flat papules, vegetations, etc., also require 
bathing with soap and water, especially when situated at the mucous 
outlets of the body or on the scalp. When the secretion is offensive in 
odor, formalin, boric or carbolic acid, thymol, or chlorinated soda should 
be added to the lotion. Cleanliness, indeed, is more essential to the 
syphilitic patient, man or woman, than to the healthy. After the 
cleansing or disinfecting ablution the parts should be dressed with a 
powder, such as dry calomel, europhen, iodoform, iodol, hydro-naphtol, 
bismuth subnitrate, zinc oxide, sodium salicylate, or starch. Vegetat- 
ing lesions of these regions may require also pencilling with a crayon 
of silver nitrate. Ointments, as containing grease, are decidedly ob- 
jectionable local applications. 

Crusted and ulcerative lesions, large or small, are to be treated in 
accordance with general principles. Crusts should always be removed 
either by the oil and soap-and-water treatment, or with a dermal 
curette, after which removal the underlying ulcers should be cleansed 
thoroughly, pencilled with silver nitrate, filled with powdered boric 
acid, iodoform, iodol, or calomel, or touched with a 5 to 20 per cent, 
solution of carbolic acid, and then be dressed with a dilute ointment of 
mercuric nitrate, 1 to 2 drachms (4.-8.) to the ounce (30.). Large 
syphilitic ulcers are often encountered on the surface of the lower ex- 
tremities, and in this situation elastic compression by a rubber bandage 
will greatly accelerate their cicatrization. 

The syphilodermata are in general amenable to the action of the 
mercurial vapor-bath, which may be regarded as exerting upon them 
both a local and a constitutional influence. Those affecting the face 
are thus benefited by exposure to the metallic vapor in the " head- 
piece" arrangement already described. The patient may less com- 
fortably also avail himself of the same local treatment by holding the 
breath and exposing the head and face for a few minutes at a time to 
the fumes of the mercury beneath the blanket, in the plan described 
as practicable at the bedside. 

It is within reasonable bounds to assert that the syphilodermata, if 
treated locally by the measures described as useful in non-syphilitic 
cutaneous affections of similar type, will proceed to a satisfactory invo- 
lution if the general treatment be skilfully ordered. 

The local treatment of syphilitic lesions of the mucous surfaces is 
both hygienic and medicinal. Catarrhal conditions of adjacent mucous 
surfaces (vagina, nasal cavity) require attention. The parts should 
be kept free from all irritation (tobacco in all forms, iced and hot 
articles of food and drink, condiments, acetous and alcoholic fluids 
in the mouth ; coitus and irritating injections of vulva ; napkins that 
have been soiled over the anogenital regions of infants). Locally, the 
silver-nitrate crayon, used as a pencil, is effective in the management 
of moist patches, applied once daily or every second or third day. 
Occasionally stronger caustics are required, such as mercuric nitrate 
or nitric acid. Mouth- washes containing potassium chlorate, myrrh, 
and honey; 15 to 20 drops in water of Bellamy's iodized phenol; 
borolyptol ; very dilute lotions of tincture of ferric chloride ; or dilute 
muriatic acid, a teaspoonful to a pint of sweetened water ; and carbo- 



CHANCROID. , 665 

lated washes, are required in different cases. In very great soreness 
and tenderness of the mouth only the blandest applications are tolerated, 
such as thin flaxseed-tea, oatmeal-gruel as a wash, and gum-acacia 
water. A few formulae are appended : 

R Potass, chlorat., 3j ; 4 

Mel. despumat.,) -- * . ,- 

Myrrh, tinct., } aa gss, ID 

Aq. dest., ad gvj ; ad 180 M. 

Sig. A teaspoonful in water as a wash for the mouth and throat. 

R Acid carbolic., 3j ; 4 

Glyc^rin^ "' } aa 5ss; ™ 2 

Spts. vin. rectif., 3ij ; 8 

Aq. dest., ad fgj; ad 30 M. 

Sig. Fifteen to twenty drops as a lotion in water, for the mouth. 

R Potass, chlorat., 3j 4f 

Aq. menth. piperit., aa ^vj ; aa 180l M. 

Sig. Gargle and wash for the mouth ; to be used slightly diluted. 

The internal management of these cases is that demanded by the 
general condition of the system and the stage of the disease, as ex- 
plained in the concluding pages of this chapter. 

Prognosis. — The prognosis of syphilis is in general favorable, pop- 
ular opinion on the subject being at variance with fact. Benignant 
syphilis may disappear without treatment. 

Malignant forms of the disease may, but rarely do, destroy life. The 
element of treatment, both as to its character and the period of its con- 
tinuance, enters more largely into the estimate upon which a prognosis 
rests than it does in most other disorders exhibiting cutaneous symp- 
toms. Syphilis untreated, whether because of failure to recognize its 
character, or of ignorance, poverty, neglect, or dissipation, is usually 
grave. The same may be said of syphilis occurring in strumous, tuber- 
culous, and cachectic subjects, and in those enfeebled by age, by other 
diseases, by chronic alcoholism, or by sexual excesses. Hereditary 
syphilis is by far the gravest form, not merely because of the tender 
age of its victims, but also because they, at the earliest period of their 
lives, are burdened with a disease which may first attack organs essen- 
tial to life. 

The majority of adult white patients, with hygienic environment, 
sooner or later recover from the acquired disease, marry, and beget in 
the end sound children. 

CHANCROID. 

This term has been adopted generally in America and England for 
the purpose of designating the virulent, local, contagious ulcer of the 
genitals, designated also as the " simple," the " soft," or the " non- 
infecting " chancre, the chancrelle of French authors. Chancroid has 
no relation to syphilis, nor to the neoplasmata with which syphilis is 
commonly classified. As it is, however, a disease with which the initial 



666 NEW-GROWTHS. 

sclerosis of syphilis may be confounded, and is also not merely a venereal 
lesion, but one which may be encountered upon the skin as well as 
upon mucous surfaces, it is briefly described in this connection. 

Chancroids present as distinct a uniformity of feature as the lesions 
of vaccinia or of herpes zoster. They are thus stamped with special 
and readily recognized characteristics, differing in this respect from 
the various modes in which the first lesion of syphilis may declare its 
nature. The virus, for such it must be termed, of the disease is one 
sui generis, and derived exclusively from lesions of like character. This 
virus, which is contained in a purulent secretion, is capable of trans- 
mission by inoculation and auto-inoculation. After such successful 
inoculation there is no period of incubation. The results of experi- 
mental generation of the virus in human subjects indicate that the 
pathological process which it awakens can be determined within twenty- 
four hours after its introduction within the skin. At times, after acci- 
dental infection, eight and ten days elapse before the lesion of the dis- 
ease is manifested, cases presumably in which the virulent secretion 
has remained pocketed in the orifice of a follicle or in a fold of mucous 
membrane, where its irritant effects have finally opened an avenue for 
its deeper ingress. When typically developed the chancroid is seen 
to be a pustular lesion, frequently multiple, of roundish outline, begin- 
ning as a pinhead-sized, turbid vesico-pustule, rapidly enlarging to 
a pea- or bean-sized, well-developed, projecting, yellowish, globoid 
elevation of the epidermis, filled with greenish-yellow pus. When 
located in furrows or depressions of the surface it may have a linear, 
oval, or even a dumb-bell shape, the latter in consequence of extension 
from a sulcus to overlying folds. Clinically the roof-wall of this pus- 
tule is not frequently encountered, the objective symptoms being the 
ulcers which represent the floors of separate lesions. These ulcers 
vary with the shape of the superimposed pustules, being round, ovoid, 
or linear, occasionally irregular in outline, with sharply defined or cut 
edges ; they have an uneven, pus-bathed floor ; a faint pinkish areola ; 
a supple, non-indurated base ; an abundant puriform secretion ; and 
are accompanied or unaccompanied by pain, according to the degree 
of inflammation present. In consequence of the auto-inoculability of 
the discharge these ulcers frequently give rise to others in the vicinity, 
as when the prepuce lies in contact with chancroids of the glans. 

The ulcers thus presented usually attain an average size of that of 
a pea or of a bean in the course of from ten to fourteen days ; they 
then remain in an indolent and suppurative condition, showing no ten- 
dency to heal for a fortnight or three weeks ; and finally they granulate, 
exhibiting the ordinary phases of repair. The resulting cicatrix is 
either transitory or, more often, indelible. In exceptional cases the 
ulcer spreads widely. In the groin it may attain a diameter of several 
inches ; its floor secreting scantily ; its edges lurid, undermined, pur- 
plish, or ragged ; its color reddish, bluish, purplish, or leaden. Fis- 
tulous tracts and sinuses, filled with an ichorous sero-pus, radiate in 
dependent situations ; the base of the sore is densely indurated ; its 
career may be prolonged for years, and induce finally a systemic 
cachexia not different from that seen in all chronic ulcerations of 



CHANCROID. 667 

severe grade. In other cases the occurrence of gangrene, or phage- 
dena, changes the features of the lesion to those of other ulcers under- 
going similar metamorphosis. 

Chancroids may occur upon any exposed mucous surface of the geni- 
talia of both sexes, upon the integument of the penis, scrotum, labia, 
thighs, fingers, perineum, peri-anal region, and, very rarely indeed, 
upon the face. In consequence of their tendency to relapse, their 
abundant contagious secretion, and their auto-inoculability, chancroids 
are more frequently encountered than is the primary syphilitic lesion 
among the filthy, the poor, and the classes that frequent hospitals and 
dispensaries. Among the wealthy, the well-to-do, and the cleanly 
this order of frequency is reversed. 

The chancroid ulcer is also much more frequently complicated by 
surgical accidents than is the infecting lesion of syphilis. This result 
is partly due to the prevalence of an ulcerative type in all its manifes- 
tations, and in part to its situation. Thus, the ulcer is often accom- 
panied by severe inflammatory symptoms, which may be aggravated 
both by phimosis and paraphimosis, occurring with stenosis of the 
preputial aperture, or with a long, lax, and redundant foreskin. Pha- 
gedena is also a formidable complication, whether of sloughing or of 
serpiginous tendency, the lesion in each case losing its chancrous char- 
acteristics. It is evident also that the disease may coexist with others 
of a different character. Thus, a single point may simultaneously be 
inoculated with chancroidal and syphilitic virus ; the former, without 
an incubative period, followed rapidly by a pustular or an ulcerative 
lesion ; the latter, after its incubation is complete, producing the char- 
acteristic symptoms of an initial sclerosis. Chancroids may also be 
found coexisting with secondary and tertiary syphilitic lesions of the 
genitals, with vegetations, with blennorrhagic discharges and balanitis, 
with pediculi of the pubes, and with herpes progenitalis. Patients of 
the class exhibiting these lesions not infrequently present themselves at 
public dispensaries with three or more of these concurrent disorders. 

One of the most serious complications of the chancroid is its associa- 
tion with a specific lymphangitis, periadenitis, or adenopathy. In this 
case the lymphatic trunks connected with the lesion become inflamed, 
indurated, and irregularly corded, with the overlying integument often 
cedematous, reddened, and painful. The infective process in these 
vessels rarely terminates by suppuration. The bubo of chancroid is 
more common, and this adenopathy may be either sympathetic, resulting 
from the severity of the process at the site of the lesion, or be virulent, 
due to the transmission of an inoculable pus to one or more of the 
glands in near connection with the source of the trouble. These dif- 
ferent gland-complications may coexist in one person, in men more 
often than in women, and in about one of each four or five cases pre- 
sented to observation. When inoculable pus has been formed in a 
neighboring gland the latter is at once converted into the seat of an 
abscess, the pus of which, whether evacuated spontaneously or by the 
knife of the surgeon, speedily inoculates the lips of the wound through 
which exit has been obtained. The wound and contiguous abscess- 
cavity then form a large chancroidal ulcer, usually inguinal in situation, 



668 NEW-GBOWTHS. 

as the glands in this locality are nearest the most frequent seat of the 
lesion. Such an inguinal ulcer discharges a greenish-yellow pus often 
commingled with blood; its borders are undermined, thin, livid or 
purplish, and ragged ; its floor is irregular, sloughy, and often covered 
with nodules representing the debris of glandular structure; from it 
depart sinuses traversing the tissues in the vicinity, often downward to 
the thigh, occasionally upward over the belly. When occurring in 
strumous and cachectic subjects, or when long neglected or mismanaged, 
the resulting disorder is of the most serious character, and it may 
surpass in duration and severity certain of the varieties of lupus and 
epithelioma. 

These facts have an important bearing. It is true that syphilis is a 
constitutional disease, and that it usually occurs but once in a lifetime. 
It is equally true that the chancroid is evidence of a local and non- 
systemic disorder, producing only such constitutional effects as may all 
other local affections of chronic course and severe grade ; but it is a 
blunder to suppose for these reasons that the chancroid is the milder 
of the two maladies. Many of its consequences are much more severe, 
and some of them even more malignant, than the average of syphilitic 
sequels, and even, as indicated above, are worse than some forms of 
other diseases usually classed as malignant. Greater attention should 
be generally directed to the truth respecting the comparative gravity 
of the two diseases, as there is widespread ignorance of the facts. 

The Pathology of the chancroid, though illustrated by the re- 
searches of Biesiadecki, Auspitz, and Unna, is yet not understood to 
an extent that will explain its specific character. The micro-organisms 
discovered in all coccogenous lesions are usually abundant and readily 
demonstrable. Those recognized by Ducrey, of Naples, 1 are short, 
thick bacilli measuring 1.46 by 0.50 fj>. These observations were con- 
firmed by Krefting, of Christiania; 2 while the bacilli discovered and 
claimed as pathogenic by Unna (his observations being later confirmed 
by Quinquaud and Nicolle) occur in the form of twisted coils and 
chains, measuring 1.25 by 0.33 fi. The etiological value of these ob- 
servations remains to be determined. 

Anatomically, there is disclosed by the microscope a uniform, dense 
infiltration of the corium with elements which undoubtedly represent 
inflammatory metamorphosis of the connective tissue of the derma ; de- 
generative changes where the ulceration has proceeded superficially ; 
enlargement of vessels from thickening of their walls, often with 
diminished lumen ; and relatively intact rete and corium at the lateral 
borders of the ulcer. This fully confirms the inferences suggested by 
a clinical study of the disease. Many roundish, circumscribed, clean- 
cut ulcers with purulent floors occur upon the skin that bear no rela- 
tion to the chancroid disease. It is the history and career of the disease 
that stamp it with an individuality of its own. It is not the form and 
appearance of its pus-elements, but their power and potency, which 
make them singular. 

Diagnosis. — Chancroid is to be distinguished from syphilitic 

1 Congres internat. ,de Derm, et de Syph. Paris, 1889. 

2 Arch. f. Derm. u. Syph., 1892, Erganzungshefte, S. 41. 



CHANCROID. 669 

chancre, but no skill, however great, and no experience, however wide, 
will enable the diagnostician, even when typical chancroid is present, 
to assert that syphilis will not follow, until the longest incubative 
period of the initial sclerosis of the last-named disease has elapsed 
without production of suspicious symptoms. The rule which neces- 
sarily follows is imperative, and, being too frequently ignored, bitter 
disappointment on the part of the infected individual, and keen 
mortification on the part of the physician, have naturally resulted. 

No PATIENT SUFFERING FROM A CHANCROID CAN BE PROMISED 
IMMUNITY AGAINST SYPHILIS UNTIL TWO AND A HALF MONTHS 
HAVE ELAPSED AFTER THE DATE OF LAST EXPOSURE. Subject 

to this essential reserve, the diagnosis rests upon the pustular, ulcer- 
ative, and discharging features of the chancroid, its failure to indu- 
rate at the base, its auto-inoculability, its appearance without pre- 
vious incubation, its more formidable localized expression of disease, 
and the characteristics of the accompanying adenopathy. The short- 
lived, superficial vesicles of herpes progenitalis, often accompanied by 
tingling and painful sensations, with sequels in the form of equally 
superficial, epidermal excoriations, are not to be confounded with chan- 
croids ; yet it must be remembered that these lesions may also precede 
or may accompany any form of venereal disorder. Chancroids are to 
be distinguished also from secondary and tertiary lesions of the genitals, 
and from non-syphilitic vegetations and molluscum epitheliale of the 
same region. 

Treatment. — The most effective and ultimately the most satis- 
factory treatment of chancroids is by asepsis patiently carried out. 
Less satisfactory is the routine treatment by destructive cauterization 
with either nitric or sulphuric acid. Keyes recommends a previous 
application of pure carbolic acid, in order to benumb the part and 
thus render the subsequent application less painful. If employed at 
all, the carbolic acid should carefully be wiped from the sore before 
the subsequent cauterization, as the two acids will explode if suddenly 
brought in contact. As the slough separates the ulcer may be dressed 
in accordance with the general principles governing the treatment of 
simple granulating wounds. Special care should be taken by all prac- 
ticable measures to avoid the possibilities of auto-infection. Vinous, 
carbolated, and opiated lotions, painting with a saturated aqueous solu- 
tion of pyoktanin-blue, powders of boric acid, iodoform, iodol, calomel, 
bismuth subnitrate, and starch, simple unguents, and the interposition 
of a pledget of borated cotton between all affected and sound tissues — 
thftse measures in most cases suffice to insure relief. Pencillings with 
silver nitrate, though ineffective for the purposes of cauterization, often 
answer a good purpose in hastening repair. The prepuce may require 
division or circumcision. 

For grave and extensive ulcerations, accompanied or unaccompanied 
by phagedena or by gangrene, there is no treatment comparable in 
value with the hot water-bath of an average temperature of 98° F. 
For the details of this method the reader is referred to the paragraph 
devoted to the treatment of syphilitic chancre. 

Phimosis and paraphimosis, when complicating chancroids, require 



670 NEW-GROWTHS. 






the surgical treatment appropriate for the relief of those conditions. 
For the accompanying adenopathy in chancroid disease, before sup- 
puration has occurred, rest is essential, with laxatives and gentle local 
compression. When there are great heat and tenderness a few leeches 
may be applied. After pus has formed it may be evacuated with an 
aspirator-needle, or by a free incision in the long axis of the swelling, 
followed by curetting the abscess-cavity and by the usual antiseptic 
dressings. Constitutional treatment by iron, quinine, cod-liver oil, and 
the employment of a generous diet with milk, malt liquors, or wines 
are often required in broken-down and debilitated persons. 

The Prognosis, in uncomplicated cases, is generally favorable. The 
scar left by a suppurating gland in the groin is indelible, but it becomes 
less conspicuous with years. Sloughing and gangrenous sores leave 
deforming cicatrices, especially when occurring at the apex of the glans, 
to which they usually give a peculiarly truncated shape. A just reserve 
should be made in all cases complicated with syphilis or extensive 
fistulous sinuses, the latter, as mentioned above, often persisting for 



years. 



LEPRA. 

(Gr. leirpbg-, scaly.) 



(Satyriasis, Elephantiasis Gr^ecorum, Leontiasis, Lepra 
Arabum, Leprosy. Fr. 9 Lepre, Ladrerie; Ger., Aussatz; 
Hal., Lebbra ; Norweg., Spedalskhed.) 

Leprosy is a disorder that has been recognized for centuries as one 
of the scourges of the human family. It is not known to affect the 
inferior animals. It is to-day endemic in many countries. 

Symptoms. — In whatever form leprosy may ultimately be mani- 
fested, its appearance is usually preceded by the prodromic symptoms 
generally recognized as precursors of severe constitutional disease. 
These symptoms are : anorexia ; cephalalgia ; chills, alternating with 
mild or with severe febrile attacks ; depression ; gastro-intestinal dis- 
turbances ; and insomnia. Their duration is exceedingly variable ; in 
some cases patients will remember that these or similar symptoms pre- 
ceded for years the earliest outbreak of lepra. In other cases but a 
few weeks' interval occurs between the prodromic and the successive 
stages of the disease. It is worthy of note that the character of the 
prodromata furnishes no clue to the severity and type of the oncoming 
disorder. The earlier cutaneous lesions of leprosy are tubercular, 
macular, or bullous. They may be coincident or successive, or one or 
two of these types may so far predominate that another may be either 
altogether wanting or may possess in the general pathological history 
but a trifling significance. It has thus been customary to make an 
entirely artificial distinction between cases of leprosy by assigning 
them to three varieties — tubercular, macular, and anaesthetic. It will 
be understood, then, in separately considering these three forms, that 
the distinction between them is useful simply for purposes of clinical 
classification ; that mixed cases of the disease occur which it would be 
difficult to assign to .either variety exclusively ; and that each case 



LEPRA. 



671 



merely represents a predominance of certain lesions at one patho- 
logical epoch. It should be noted also that the symptoms of leprosy 
are remarkable for their polymorphism, a wide variation often exist- 
ing between the character of two or more lesions which at any given 
moment are apparent. This variation is largely owing to the fact 
that leprosy is a general and constitutional disorder, the cutaneous 
symptoms of which are simply its surface-markings. 

Lepra Tuberosa (Tuberculated, Nodulated, or Tegumentary 
Leprosy). — Tubercular leprosy commonly begins in the skin with 
macular lesions, which are bean- to tomato-sized, reddish, brownish, or 
bronze-hued patches ; roundish, oval, or irregular in contour ; and 
occurring upon the face, trunk, or extremities. The skin covering 
these lesions is either smooth and shining, as if oiled, or is moderately 

Fig. 77. 




Lepra tuberculosa. (After Danielssen and Boeck.) 

infiltrated and elevated. After a period ranging in duration from 
weeks to years, tubercles (lepromata) rise from the maculations, vary- 
ing in size from that of a pea to that of a nut, though they may be as 
large as a tomato. They are yellowish, reddish brown, or bronzed in 
color, often shining as if varnished or oiled, are covered with a soft, 
natural, or slightly desquamating epidermis, roundish or irregular in 
contour, and are either isolated or grouped. Numbers of very small 
and ill-determined nodules may often be recognized by careful exam- 
ination of the skin in the vicinity of those fully developed. They 
may be either cutaneous or subcutaneous in situation, and be softish 
or firm to the touch. The eruption of these tubercles is usually at the 
outset preceded by fever as well as by oedema of the region involved. 

The site of predilection of leprous tubercles is the face ; and their 
massing in great numbers upon this region produces the characteristic 



672 



NEW-GROWTHS. 



deformity of the countenance that has given to the disease one of its 
names, Leontiasis (face of a lion). In such faces the tubercles are 
ranged in parallel series above the brows, down the nose, over the 
cheeks, the lips, and the chin. In consequence of the infiltration 
and development of the lesions the brows deeply overhang the globes 
of the eyes, the eyelids become affected with partial ptosis, the lips 
pout, and the ears are so studded with tubercular masses as to project 
from the side of the head. The trunk and extremities, including 
the palmar and plantar surfaces, are then usually to a less degree 

Fig. 78. 




Tubercular leprosy. (From a photograph of a leper in the Sandwich Islands.) 

involved. Occasionally, indeed, with extensive development of tuber- 
cles upon the face and ears, there may not be more than from five to 
fifty tubercles upon the rest of the body, and these either widely dis- 
persed and isolated, or agglomerated in a single, hard, flat, elevated 
plaque of infiltration upon the elbow or the thigh. When confluence 
of tubercles occurs large plaques of infiltration may form (lepromcs 
en nappe), which are elevated and brownish or blackish in shade (mor- 
phoea nigra). In yet other cases the condition described by Bazin as 
leprous scleroderma occurs, in which dense infiltrations extend to both 
the derm and the hypoderm. The surface of these lesions is roughened, 
often desquamating, rarely ulcerated. 



LEPRA. 673 

With these cutaneous lesions there is often involvement of the 
mucous surfaces, especially the velum palati and the larynx. In the 
case of a leper affected with the tubercular form of this disease, who 
was exhibited at our clinic in 1879/ there were marked gruffness and 
hoarseness of the voice, and the larynx and velum were studded with 
pinhead- to pea-sized, ashen-hued tubercles. Others may form upon 
the conjunctiva and the Schneiderian membrane, the gums, the inside 
of the cheeks, the tongue, the palate, the fauces, and the pharynx. 

These tubercles may degenerate into ulcers, or may undergo resorp- 
tion and disappear, leaving pigmented atrophic depressions, or they lose 
their shape in consequence of partial resorption. A large plaque may 
flatten centrally until an annular disk is left to indicate its former site. 

Among the coincident symptoms of the tubercular exanthem in lepra 
may be named : disturbance in the functions of sweat and sebaceous 
secretion, thinning and loss of the hair in the regions implicated (espe- 
cially of the eyebrows) and disorders of sensibility. 

It should be borne in mind, however, that the course of the disease 
is exceedingly slow, and that years may elapse before these several 
changes are accomplished. The malady, indeed, often appears to be 
quiescent for months at a time, after which, with the occurrence of 
fever, acute or subacute manifestations appear, and a relatively rapid 
progress is made toward a fatal conclusion. Long before the latter is 
reached there are usually, in tubercular leprosy (Fig. 79), intermingled 
symptoms of anaesthetic type, such as the occurrence of bullae or of 
anaesthetic patches with and without pigmentation. Toward the last 
the mutilations effected by the disease may result (Lepra Mutilans). 
Phalanges of the fingers or toes, whole digits, an entire hand or foot 
may then become wholly or partially detached by ulcerative, atrophic, 
or other degeneration of skin, bones, and ligaments, hastened or not 
by intercurrent attacks of lymphangitis, erysipelas, septicaemia, and 
irritative fever. 

The stadium of this type of the disease may extend through ten or 
more years. After its full development the dejected countenance of the 
leper, with his leonine facies and general appearance of cachexia, is 
highly characteristic. 

Lepra Maculosa (Erythema Leprostjm, Leprous Eoseola). — 
This form of the disease is chiefly distinguished, as its name implies, 
by its macular lesions. These lesions have the general character of 
those described as preceding the appearance of the leprous tubercles. 
They are diffused or circumscribed, roundish or irregularly shaped, 
and in color yellowish, brownish, or bronzed, often shining or glazed. 
They may be infiltrated, and may be slightly raised from, or on a level 
with, the adjacent tissues. At times they appear as lardaceous deposits 
in the skin, whitish, reddish, or even blackish in color, with a telang- 
iectasic border. These patches are usually at first hyperaesthetic, but 
finally they become insensitive, so that a lancet can be thrust deeply 
into them without producing the slightest sensation. 

The pigment- variations in macular lepra are noticeable. At times 

1 Chicago Med. Jour, and Exam., December, 1879, with cut showing appearance 
of larynx. 

43 



674 NEW-GROWTHS. 

a distinctly anaesthetic patch may readily be limited by its lack of 
sensation and of normal color; at other times either symptom may 
fail to correspond with the area of involvement defined by the other. 
Thus, a palm- to platter-sized, texturally unaltered area over the thigh 
or the belly may suggest a vitiligo by its relatively slight pigmenta- 
tion and its distinct contour, beyond which are sepia to deep chocolate 
tints, gradually fading toward some adjacent and similarly involved 
patch. Yet this area will often differ materially from that of vitiligo 
in other respects. Every inch of the former may be totally insensi- 
tive to the prick of the lancet, and, moreover, be of a dull, tawny, 
yellowish, or parchment-like hue, never having the peculiar milky- 
white tinge of vitiligo. Again, this anaesthesia may extend widely 
beyond the line traced by the pigment-anomaly, or even within the 
latter may vary, islets of skin capable of perceiving sensation being in 
cases here and there discernible. The regions chiefly affected are : the 
exposed parts, the backs of the hands and wrists, the forehead, cheeks, 
ears, dorsum of feet, and ankles. 

Lepra Anaesthetica (Lepra Trophoneurotic a, Nerve-leprosy, 
Atrophic Leprosy). — This clinical variety, as has been described, may 
be commingled in its symptoms with each of the other types. With 
and without such commingling, however, there is commonly noted after 
exposure to cold, or after being subject to chills, first an eruption of 
erythematous patches or of bullae, bean- to large-nut-sized, with a roof- 
wall constituted of the entire thickness of the epidermis, filled with a 
clear-tinted or blood-mixed serum, occurring usually upon the extremi- 
ties. The cicatrices which follow these bullae are atrophic patches, each 
often far greater in extent than the base of the original bleb, whitish, 
shining, glazed, or better described as of a tint suggesting the hue of 
mica ; circular in outline, forming also the dumb-bell figure by coales- 
cence or juxtaposition. These cicatrices are always anaesthetic, and 
they may coexist with macular and anaesthetic patches upon the trunk 
or other portions of the body : face, hands, feet, ankles, thighs — rarely 
the palms and soles. Neither those of the one class nor of the other, 
however, are disposed over the surface of the body in lines, bands, or 
curves corresponding with the distribution of the cutaneous nerves. 
Asymmetry is the rule. Occasionally, however, the ulnar and other 
nerves (median, posterior tibial, peroneal, facial, and radial) accessible 
to the touch are tumid, tender, insensitive, or as rigid as indurated 
cords ; fusiform, reddish-gray swellings may be recognized with the 
naked eye along the nerve-tract, with translucent and gelatinous aspect. 
General atrophic cutaneous symptoms follow : the skin becomes dry 
and harsh ; there is manifestly little or no sebaceous product ; the sweat 
is scanty ; the muscles atrophy ; the hairs fall ; the lymphatic ganglia 
enlarge ; the skin of the face seems tightly stretched over the bones. 
As a result of deforming atrophy of the eyelids epiphora and conse- 
quent orbicular changes ensue, and the parted lips permit constant 
escape of saliva. The fingers are half-drawn into the palm of the 
hand ; the nails are distorted, and, later, ulceration occurs (Fig. 79). 

The ulcers are irregular, oval, roundish, linear ; covered with thin, 
blackish, flattened, tenacious, never rupioid, crusts ; their bases are 



LEPRA. 



675 



soft ; their floors covered with a pultaceous debris often mixed with 
blood ; the whole usually insensitive to every foreign body and external 
application. Lastly, the symptoms of lepra mutilans may occur, digits, 
or portions of the carpus, metacarpus, or corresponding parts of the 
foot, being detached from the body. 

Death may ensue, at any time during the course of the disease, from 
septicaemia, exhaustion, or any of the intercurrent affections to which a 
patient in such a condition is particularly disposed. Thus, a leper was 
accidentally choked to death in San Francisco by some perversion of 
the function of deglutition. The disease, however, in the anaesthetic 
form is said to last from eighteen to twenty years, and is thus less 
rapidly fatal than the tubercular variety. 



Fig. 79. 




Anaesthetic leprosy with mutilating results. (From a photograph of a leper in the Sandwich 

Islands.) 

Considering the several clinical varieties of leprosy named above, 
and the mixed forms resulting from a commingling in some cases of 
the features of all varieties, the result is merely an analysis of the 
symptoms in an enormous clinical field. There are not, in fact, any 
forms or varieties of this disorder ; there is but one disease, which ex- 
hibits itself in widely differing manifestations, and these at one time 
and in one country assume a predominant phase, while with a differ- 
ent environment and in another race other phenomena appear. Thus, 
lepra tuberosa is reported in from 50 to 75 per cent, of patients affected 
with the disease in the north of Europe, and in from 10 to 20 per cent. 



676 NEW-GROWTHS. 

of those in tropical countries ; while anaesthetic lepra in the geograph- 
ical limits last named is represented by two-thirds of patients, and in 
the northern latitudes by less than one-third. " Mixed forms " are less 
often reported than others, but as a matter of fact are the more often 
observed. The reason for this apparent anomaly lies in the fact that 
really pure cases of any form are rare. It is best to look upon the 
expressions of lepra as it is accepted to regard the phenomena of syph- 
ilis : in each there is a single morbid principle ; there are in both no 
true varieties ; and the external symptoms differ chiefly because of 
special accidents of environment, of race, or of individual peculiarities. 

Looking at the variant symptoms of lepra, a wide range occurs in 
all stages. In the evolution of the disease there is a usual order of 
fever, eruptive symptoms, and ulcerative or destructive sequels. In 
the prodromic period there are often chilliness, profuse diaphoresis, in- 
somnia, inappetence, diarrhoea, vertigo, and even a bullous efflorescence 
upon the surface. These prodromata are rarely wanting, and, after 
lasting for weeks, months, or years, are followed by sensations of chil- 
liness, with remitting or intermitting febrile symptoms, the temperature 
rising from 100° to 105° F. The tongue becomes of a reddish hue, 
the listlessness and sluggishness continue, and the typical cutaneous 
lesions of the disease (leprous spots) appear, commonly on some portions 
of the face, with or without oedema. In some cases the prodromic 
symptoms and fever and chilliness are either absent or, what is more 
probable, are unnoticed, and then the disease may be first recognized 
by pains of a lancinating character, tenderness, and aching, especially 
along the course of the ulnar, peroneal, median, saphenous, or other 
nerves ; or the result may be hyperesthesia, anaesthesia, or pricking, 
tingling, and similar sensations in regions supplied by special nerves. 
The greatest variation is observed in the length of time during which 
these early symptoms, with more or less vagueness of expression, exist. 
Later, tubercles, nodules, bullae, macules, hyperaesthetic and anaesthetic 
patches appear with gradual development of other and non-cutaneous 
symptoms, paralysis, exaggerated tendon-reflexes, and atheromatous 
papules upon the palpebral membranes and cornea. At times there 
results an ulcerative keratitis. In every large leper-hospital the number 
of inmates, both men and women, who have become totally blind in 
consequence of the ravages of the disease is considerable. In many, 
too, nodules appear over the chest, genital regions, and extremities, as 
well as upon the mucous surfaces of the mouth and respiratory tract. 
The voice becomes raucous, wdiile recrudescences of the disease occur 
either along the one (tubercular) or the other (anaesthetic) line toward 
the final stages of degeneration and mutilation. 

The disease in seen in all typical forms, even in regions where leprosy 
is least prevalent. There may be a genuine leprous pachydermia with 
enormous increase in the volume of the hands and feet, accompanied 
by severe onychia and paronychia, and deep ulcerations about the nails. 
In some cases tumefaction of an entire limb results, strongly resembling 
an elephantiasis. The nose may be stuffed with leprous tubercles ; and 
a large number of cutaneous symptoms of the most varying type 
develop in and upon the leprous skin as the result of secondary infec- 



LEPRA. 677 

tion, of accidents, or of invasion by pus-cocci, etc., for it must be remem- 
bered that in most cases the leprous belong to the filthy and impover- 
ished classes of society. Thus, there are often developed eczemas, 
erythematous and achromic and hyperchromic spots and disks, annu- 
lar lesions resembling those seen in syphilis, bullae rapidly becoming 
gangrenous (erytheme polymorphe lepreux bulleux et escharotique, of 
Leloir), nodules of the usual size and hue of those in lepra (pinhead- to 
nut-sized, pigmented, reddish brown, copper tinted, glazed, shining as 
if oiled), and enormous infiltrations within and below the derma, even 
the production of large tumors of leprous tissue. 

The generative apparatus may seriously be involved, the uterus, 
Fallopian tubes, and ovaries being the seat of leprous nodules or diffuse 
lepromatous infiltrations ; as may be also the testicles, prostate gland, 
and penis. The breasts are also stuffed with tubercles ; but they, as 
also the other organs named, may simply waste under the influence 
of the disease. Sexual power is retained longer than is commonly 
believed. In the colored races the eruptive symptoms are tinted in 
yellowish and reddish shades, a result due to contrast with the hue of 
pigmented skins. 

Etiology. — Leprosy is a contagious and infectious parasitic disorder 
produced by the bacillus leprae. This organism was discovered by 
Armauer Hansen in 1874, and is present in large numbers in tubercular 
forms of the disease, being relatively absent in anaesthetic lepra. It 
strongly resembles the bacillus of tuberculosis. These bacilli have been 
found in the dwellings and clothing of lepers as well as in the dust of 
apartments occupied by victims of the disease. 

Secretions of a leprous patient containing bacilli or their spores are 
the usual vehicle by which the disease is transmitted. The question 
of the inheritance of leprosy may be regarded to-day as in much the 
same position as that relating to the inheritance of tuberculosis ; no 
foetus, no newborn living child has been known to exhibit the symptoms 
of either disease. Men are more often affected w T ith the disease than 
women. Infection is more common after the second decade, though 
children are occasionally among its victims. 

The geographical distribution of leprosy is widely extended. In 
countries where it has not previously existed 
its appearance is invariably due to the infec- Fig-^80. 

tion of sound individuals by lepers first ex- 
hibiting symptoms in a country where the 
disease is prevalent. Neisser formulates the 
law of its prevalence by stating that the 
number of lepers in any country bears an 
inverse ratio to the laws executed for the care 
and isolation of infected persons. 

The disease exists in the interior and 
throughout the seaboard regions of Africa, Larvnx of a patient affected 
including Egypt; in Arabia, Syria, Persia, Stho^"' l ° ne ° fthe 
China, Japan, and India ; in the islands of 

the Mediterranean, Black, Caspian, and China Seas, of the Indian 
Ocean, and of the Australasian Archipelago ; in Norway and Sweden, 




678 



NEW-GROWTHS. 



Iceland, Russia, Turkey in Europe, Spain, France, Portugal, Greece, 
and Italy; and sporadically in Germany, England, and the smaller 
European States ; in North, Central, and South America, and the 
West India Islands. In America special attention has been directed 
to the subject by the existence of the disease in an endemic form in 
the Sandwich Islands, with which the Pacific States sustain close com- 
mercial relations ; by its occurrence among Chinese immigrants in San 
Francisco and other portions of California ; by cases reported from 
New Orleans by Burns, 1 Bemiss, 2 Jones, 3 Dyer, and Solomon, 4 and by 
various reports of sporadic cases observed in Minnesota, Maryland, 
Illinois, Nebraska, New York, North and South Dakota, Pennsylvania, 
Iowa, New Jersey, Ohio, Wisconsin, and other States of the Union, by 
Gronvold, Hoegh, Bendeke, Rohe, Piffard, Elsberg, Atkinson, the 
authors, and others. White and Graham have contributed to the history 
of the colony of lepers in Tracadie, New Brunswick. More recently 
Morrow, 5 of New York, and Bracken, 6 of Minnesota, have added 
valuable data to the statistics of the disease as it exists in this country. 
With this wide geographical distribution, the disease exists endem- 
ically in certain countries, and also in certain regions of the same 
country, with greater frequency than in others. All attempts, how- 
ever, to connect its origin with malaria, with a residence near inun- 
dated sea-marshes, w r ith the ingestion of a diet consisting largely of 



Fig. 81. 



Fig. 82. 







; lb 




Larynges of lepers affected with lepra tuberculosa. (Elsbeeg's cases.) 



fish, or of a diet from which salt largely has been excluded, have failed 
of recognized success. The disease, however, seems to spread more 
rapidly in damp and cold, or warm and moist climates than in temper- 
ate countries. It is true that probably the larger number of all living 
lepers are those who have been poorly fed and otherwise subjected to 
the most insalubrious of influences, but the disease also attacks, though 
far more rarely, persons whose social position and hygienic surround- 
ings are of the best. It occurs in both sexes — though more frequently 
in males — and at all ages ; and, despite all effort to show the contrary, 
bears no relation to syphilis. Lepers, however, become syphilitic if 
infected with that disease, precisely as they may and do acquire variola, 

1 Arch, of Med., December, 1881. 2 N. O. Med. and Surg. Jour., April, 1880. 

3 Ibid., March, 1878. 4 Trans. Louisiana State Med. Assoc, 1879. 

5 Twentieth Century Practice of Medicine, vol. xv., p. 403. 

6 " Are National Leprosaria in the United States Desirable?' ' Minnesota State Board 
of Health, 1901. 



LEPRA. 



679 



varicella, morbilli, erysipelas, and phthisis. The Hebrew Scriptures 
are often interpreted as showing that the disease among the Jews in 
Palestine was regarded by them as contagious and so treated. The 
modern student of these writings will, however, be convinced that this 
interpretation is erroneous. The leprosy of the book of Leviticus not 
only includes lepra, as that term is understood to-day, but also psoriasis, 
scabies, and other cutaneous affections. The leper, in the eye of the 
Mosaic law, was ceremonially unclean, and capable of communicating 
only a ceremonial uncleanness. Several of the narratives contained in 
these books bear witness to the fact that the Oriental leper was occa- 
sionally seen doing service in the courts of kings, and even in personal 
communication and contact with officers of high rank. 

Pathology. — The bacillus of leprosy is a delicate rod-shaped para- 
site from one-half to three-fourths of the diameter of a red blood- 
corpuscle in length, and about one-fifth as broad as long. The bacilli 
of leprosy are morphologically almost identical with those of tubercu- 
losis, but are found in affected tissues in vastly greater numbers, ap- 
pearing usually in clumps, and responding more promptly to staining 
and decolorizing agents. These micro-organisms have been found in 
nearly all the tissues of the body, and especially in the skin, mucous 
membranes, interstitial tissue of the peripheral nerves, in the cartilages, 
cornea, spleen, liver, lymphatic glands, sebaceous glands, and hair- 
follicles, also less abundantly in the testicles, spermatic cords, ovaries, 
and walls of the blood-vessels. They do not occur in the muscles, 
spinal cord, bones, or joints, and are wanting in many secondary in- 
flammatory lesions, such as bullae on the surface of the skin. They 
are rarely found in the epidermis, and though it is claimed that they 
are visible in the blood, their discovery in that fluid has not been con- 
firmed. The bacilli are not found in physiological secretions unless 
these be pathologically altered by 

an organ or membrane affected with Fig. 83. 

leprous infiltration. They have 
never been found in urine or in 
menstrual blood. 

The parasites are most numerous 
in comparatively recent but fully 
developed nodes of the skin. Such 
a node on section shows in the 
centre a brownish mass or "glo- 
bus," which sometimes can be 
shaken out of the surrounding tis- 
sue, and which on examination 
proves to be composed almost en- 
tirely of masses of bacilli. Even 
in the diffuse form of infiltration 
the bacilli are usually found in 
groups or masses, but they may be 
disseminated through the tissues. 
According to Hansen and Looft, the bacilli are almost invariably situ- 
ated within a " lepra-cell," or occasionally in endothelial cells of the 




(P 

Bacilli of leprosy : a, epithelial scale. About 
X 1200. (From one of the authors' patients.) 



680 NEW-GROWTHS. 

vessels, or in white blood-corpuscles. Unna and others, on the con- 
trary, have found the bacilli without the cells. Most investigators 
agree with the observations first cited, but think it probable that there 
are a few free bacilli, and also some in the lymph-channels. 

Unlike the bacilli of tuberculosis, those of leprosy apparently do 
not live or grow outside the living human body. Campana and Ducrey 
obtained cultures, as they supposed, of the lepra-bacillus, but did not 
verify their results by inoculation-experiments, and their conclusions 
are not generally accepted. Practically, the bacillus has not yet been 
cultivated. Attempts to inoculate lower animals with leprous tissue 
have given no definite results. Numerous attempts have been made to 
inoculate human beings with leprosy, but the disease developed in only 
one of the inoculated individuals, and as he was a member of a leprous 
family the result cannot be considered conclusive. 

The introduction into living tissues of leprous material containing 
bacilli results simply in a local inflammation such as would be pro- 
duced by the introduction of any inert substance. In such experiments 
the leprous tissue, which had been hardened for months in alcohol, was 
equally effective with the fresh tissue. Besnier and others believe that 
the bacilli die with the tissue in which they have lived, and thus 
account for the failure of culture- and inoculation-experiments. The 
slight viability of the bacilli is largely responsible for the usual 
benignity and slow progress of the disease. 

In tubercular leprosy the chief histological changes are seen in the 
corium, the nodule being made up chiefly of granulation-tissue similar 
to that seen in lupus and syphilis ; but the leprous tissue is less vascu- 
lar and consequently undergoes formative and retrogressive changes 
less rapidly ; the cells are larger than in the two other diseases named, 
and do not form in nests, as in lupus. The cells, which probably origi- 
nate in endothelial cells of the vessels or in migrated cells, are seen in 
varying sizes and usually filled with bacilli to form the " lepra-cells." 
Giant-cells are also seen. 

The infiltration may be diffuse as well as nodular, and is most 
marked at first about the vessels, glands, and follicles. Later it may 
obliterate the papillae and their line of union with the rete, and extend 
to the subcutaneous tissue. The external and middle coats of the 
vessels are infiltrated and thickened and their lumen narrowed. The 
sebaceous and coil-glands and the follicles are involved early, at first 
undergoing infiltration and hyperplasia, later degenerating and disap- 
pearing. The epidermis is involved secondarily only, and may be thus 
thinned and atrophied or broken in the formation of ulcers. 

In macular and anaesthetic leprosy Hansen and Looft 1 state that 
" the macules are, like the nodules, leprous infiltrations of the cutis, 
consisting of round epithelioid and spindle-cells, the latter being more 
numerous the greater the age of the macule. These infiltrations appear 
to proceed from the vessels. Lepra-bacilli are always present, but are 
most numerous in the younger macules. In the young not as yet 
anaesthetic macules the nerve-twigs appear unchanged; in the older 

1 Leprosy in its Clinical and Pathological Aspects, English translation by Walker. 
London, 1895. 



LEPRA. 681 

ones they are usually affected." The essential nerve-changes are an 
infiltration of cells containing bacilli within the external sheath and 
between the nerve-fibres, resulting in a gradual disappearance of the 
latter as a result of pressure produced by the great increase of intersti- 
tial connective tissue. The irritation of the nerve-fibres in the early 
stages accounts for the pains and hyperesthesia ; the nerve is also 
increased in size, often to a marked degree. Later there are atrophy 
and shrinking of the nerve, of which many of the original fibres have 
been destroyed and replaced by connective tissue, with resulting anaes- 
thesia. The peripheral nerves are thus frequently affected, but in the 
brain and cord leprous changes have not been demonstrated. In a few 
cases of anaesthetic leprosy degeneration and atrophy of the posterior 
columns, posterior roots, and spinal ganglia have been demonstrated, as 
well as other changes probably due to an associated tuberculosis which 
is not infrequently present. 

Regarding the disappearance of leprous lesions and tissue, Hansen 
and Looft say that in both the nodular and the maculo-anaesthetic forms 
"the bacilli in the leprous products break up into granules which 
finally disappear, and there remains of the leprous products only a scar- 
in which nothing leprous can be recognized. Occasionally this takes 
place in all the affected parts, and there remains only a widespread 
anaesthesia, the result of the nerve-affection ; and in the maculo-anaes^ 
thetic form this is the regular termination of the disease. In both 
cases the leprosy is completely healed." Jeanselme 1 concludes that 
after complete invasion of the subject the bacilli of lepra may utterly 
disappear, leaving only a sclerosis in their track. 

Diagnosis. — Apart from the history, present and previous places of 
residence of the subject of the disease, and the clinical symptoms 
exhibited, the diagnosis of lepra is to be established by the presence of 
lepra-bacilli. These organisms may be recognized in the tissues, in 
serum obtained artificially from involved regions, in blood made to 
exude from lepromatous nodules, and in the secretions of ulcers. 
Spronck asserts that the agglutinating power of the serum of the 
leprous produces a characteristic reaction in the bacilli reproduced by 
cultures obtained by Hansen's method. 

In well-marked cases the recognition of leprosy is simple. In its 
prodromic periods no suspicion of its existence would be awakened in 
countries where the disease is not endemic. 

From syphilis, which is also a disorder the lesions of which are 
polymorphic in character, lepra can be distinguished by its much 
greater chronicity ; its larger and brownish-yellow, glazed tubercles ; 
its frequently paresthetic and anaesthetic symptoms ; its bullous lesions, 
rare in acquired syphilis ; the far more extended areas of its erythema- 
tous macules ; its blackish crusts, lacking the rupioid aspect of those in 
syphilis ; its leathery, mica-tinted cicatrices ; and the characteristic 
leonine facies of its tubercular forms. 

Morphoea and vitiligo are unattended by constitutional changes, and 
more particularly exhibit no hyperaesthetic nor anaesthetic symptoms in 
the affected patches. The atrophic and often deeply pigmented condi- 

1 La Presse med., Dec. 15, 1900. 



682 NEW-GROWTHS. 

tion of the skin in the final stages of pityriasis rubra, associated with 
the emaciation and febrile condition of the patient, might for a time 
mislead the observer who had not a full history of the case. Multiple 
sarcomata, especially upon the face, are followed by much more rapid 
degeneration and a fatal result. 

All lesions of erythema multiforme can readily be distinguished 
from those of lepra by the absence of hypersesthetic or of anaesthetic 
symptoms. Syringomyelia is differentiated by its display of lesions 
only in regions where there is also muscular atrophy ; by the much 
greater extent and lack of definition of areas of perturbed sensation ; 
by diminution of the tendon-reflexes, which may be exaggerated in 
lepra ; by a marked predominance of symptoms in the upper as distin- 
guished from the lower extremities ; and by the frequent presence of 
scoliosis. The nodules of lupus are not symmetrical, are far softer, and 
are much more often grouped than those of lepra. Further, they never 
have the size of the larger leprous tubercles, and never have the peculiar 
pigmented, brownish, and oiled or varnished aspect of leprous nodules. 

Finally, the diagnosis of leprosy requires not only clinical symp- 
toms, but also a definite contagion. Whether a history of transmis- 
sion from one individual to another be or be not obtainable, it is certain 
that no person ever manifests leprous symptoms who has not been 
infected by some victim of the disease. 

Treatment. — One of the most important considerations relative to 
the therapy of leprosy is that requiring the segregation and isolation 
of all lepers from contact with the uninfected. In some countries, 
those particularly where leprosy prevails, wholesome laws enforce this 
separation of the infected, and charitably provide also for the care of 
the wretched victims of the disease. In America, where leprosy, in 
consequence of its rarity, has not yet awakened the attention of legis- 
lators beyond the point of forbidding the entry of infected persons, 
the proper care of lepers in a community only too ready to take 
alarm even at the name of the disease is a serious matter. Many 
of the public hospitals for the care of the sick poor refuse to receive 
lepers. In several States of the Northwest the officers of health- 
boards are powerless to make proper provision for the care of a leper 
whose case is brought to their attention. In some of the American 
colonies provision is made for the care of lepers, as in Hawaii. 

The child of a leprous woman should be removed from the mother 
after birth and not given another woman's breast. 

No remedies are known to have a directly curative effect in leprosy. 
As a consequence, the treatment of the disease is that suggested to the 
intelligent practitioner by the indications in each case. Most impor- 
tant, when the patient happens to reside in a district where the disease 
prevails, is an immediate change of residence and climate ; the adop- 
tion of a highly nutritious diet ; and the exhibition of roborant reme- 
dies, including steel, quinine, cod-liver oil, and often the moderate use 
of wines and malt liquors. 

The injection of antivenene and other modes of serum-therapy 
have not been followed by results confirmed by a sufficiently wide 
experience. The cinchonas and salicylates are indicated in febrile con- 



LEPRA. 683 

ditions. Mercury, arsenic, the iodine compounds, hoang-nan in pills 
of 3 grains (0.266) ; creosote in half-drop doses (0.033) ; the oil of 
cashew-nut, gurjun balsam, chrysarobin, pyrogallol, resorcin, 10 per 
cent, solution of salicylic acid in oleic acid (Arning) ; ichthyol, and 
chaulmoogra oil, internally and externally, have all been employed 
with varying success by different practitioners ; but an unprejudiced 
review of the maximum of results thus obtained establishes the con- 
viction that no one of the remedies named may be regarded as exercis- 
ing a controlling influence over the disease. Most of them have been 
employed by physicians sufficiently wise to enforce simultaneously the 
most generous tonic regimen, thus clouding with doubt a belief in the 
part played by the medicament in the production of the result. In 
the case of a leper and his daughter in Nebraska, who were treated for 
some time with chaulmoogra oil, marked benefit was noticeable in the 
course of a few months, a result probably due to the salubrious sur- 
roundings of a farm in the country. 

Every secreting ulcer and open surface in the person of a leper re- 
quires prompt and thorough disinfection with a solution of formalin 
or mercuric chloride, or other parasiticide, in order to destroy the 
bacilli commonly present. Baths are of great value in these cases, 
and they may be medicated with any desired substance. In the local 
treatment of leprous tubercles, ulcers, and other lesions the simple 
principles, dermatological and surgical, governing ordinary cases are 
not to be forgotten. Disinfectants, carbolic and boric acids, bland 
unguents, inunctions, and local stimulation of the skin are as useful, 
when properly applied to the leprous, as to the syphilitic, the cancer- 
ous, and the scorbutic patient. 

Prognosis. — The future of the leper is indeed dark. The disease 
is malignant in character, and, however protracted, a fatal result is 
usually inevitable. Still, with a change of climate and improved 
hygienic conditions much may be accomplished. There can be no 
question that the Scandinavian lepers who have removed to the United 
States have been greatly benefited by the change. This, indeed, was 
the opinion of the late Professor Boeck, who visited Minnesota, and 
there studied the history of eighteen leprous immigrants who had come 
from Norway. He believed that the change in some cases would work 
a complete arrest of the disease. A careful study of the history of lep- 
rosy in America will induce the belief that such a favorable result can 
be anticipated after residence in the Northwestern States, as well as in 
other portions of the country. 

The Sartian Disease (Taschkent-geschwur) is an infectious 
granuloma, described by Heiman, and microscopically examined by 
Rudniew. It occurs in Taschkent, or Taschkend, a market-town of 
Asiatic Russia, west of the Caspian Sea. The disease affects the face, 
the upper extremities, and the trunk, avoiding always the palmar and 
plantar regions. Reddish macules develop into nodules, which des- 
quamate, coalesce, degenerate, and leave crusted ulcers, which may 
cicatrize. 



684 NEW-GROWTHS. 

FRAMBESIA. 

(Fr. framboise, raspberry.) 

(Yaws, Pian, Lepra Fungifera, Toboe, Polypapilloma Trop- 
ica, SCHWAMMFORMIGE, BUBA OR BOBA, BOUTON D'AMBOINE 

Tonga, Coco, Framosi, Tetia, Lupani, Tono, Peruvian 
Wart, Parangi.) 

Frambesia is an infectious disorder existing as an endemic malady 
in certain tropical countries, and affecting for the most part individuals 
of the African race. 

Contributions to the literature of this subject have been made by 
Pison Bontius, Hillary, Winterbottom, Schilling, Milroy, Nicholls, 
Imray, and Bowerbank. The description here given is largely bor- 
rowed from a paper 1 on the subject contributed by Pierez to the Pan- 
American Medical Congress held in Washington in 1893. 

Symptoms. — There are two denned stages of the disease : one of 
incubation ; another of invasion. In the first stage there may be mod- 
erate febrile symptoms ; in the second stage there are usually malaise, 
articular pains, tenderness and fulness of the lymphatic ganglia, and an 
eruption consisting of tubercles which requires from two to nine days 
for complete evolution, the disease lasting from two to six months in 
mild cases, and in severe forms for two years or more. The aggra- 
vating influences determining the longer periods of the disease are : 
lack of hygienic surroundings, improper medicinal treatment (e. g., the 
administration of mercury under the supposition that the disease is 
syphilitic), and the dyscrasias in general. The eruptive phenomena are 
described under several heads : 

(a) Pian dartre (" yaws caeca "), in which there occurs on the face 
and extremities a furfuraceous desquamation which is usually well 
defined and limited to patches ranging in size from that of a small 
coin to that of a pea. This desquamation may extend over the entire 
surface of the body. In some instances, when the scales are removed, 
papillary projections are visible beneath. 

(b) The yaws tubercle. The tubercle of frambesia varies in size 
from that of a millet-seed to that of a small coin, covered at first with 
a thinned epidermis and later forming an excrescence of verrucous type 
with numerous aggregated pinkish points which furnish a secretion, 
desiccating later into a greenish-yellow, bulky crust, shaped like the 
shell of the limpet and resembling in color and consistency lumps of 
yellow beeswax. Reddish puncta, due to small hemorrhages, may here 
and there be visible at the surface. Crusts are less likely to form 
in regions near the mucous outlets of the body (vulva, anus), and at 
points subjected to friction (axilla?, groins). There may be a delicate 
halo about each crust. The odor is mawkish. A degree of symmetry 
may be perceptible. By confluence a few unusually large excrescences 
(" mama pian ") may form. While the larger are thus coalescing and 
enlarging other smaller tubercles may shrivel and disappear. 

1 Transactions of the First Pan-American Medical Congress, Washington. Govern- 
ment Printing Office, 1895. -Part II., p. 1764. 



FRAMBESIA. 685 

(c) Pian gratelle (" guinea-corn yaws "), which is the rarest form of 
all, is characterized by the development of watery-looking, light pur- 
plish-hued tubercles destitute of crusts. 

(d) Crapeaux (" crab-yaws "). In the secases fissures occur in the 
tubercles which are usually located on the soles of the feet and are 
aggravated by the exposure of these organs when walking barefoot. 

(e) Ringworm yaws. The eruption may occur in circular ridges 
surrounding an unaffected centre, the original lesions of this enclosed 
area having undergone a species of shrivelling. "When this process is 
completed by the fall of the crusts no scars are left, the epidermis being 
pigmented as after the involution of syphilitic tubercles. 

Under unfavorable conditions ulceration of the tubercles occurs, 
leaving raw patches (often on the anterior faces of the legs) ranging in 
size from that of a small coin to areas having a diameter of several 
inches. Their edges are punched out in appearance ; the floors are 
granular and bright reddish in hue. 

Diagnosis. — The distinction between frambesia and psoriasis and 
eczema is readily effected by consideration of the distinctive peculiari- 
ties of the several disorders named. It is chiefly the distinction from 
syphilis that has engendered confusion in the past. The following are 
important points of distinction : syphilis often, yaws rarely, attacks the 
mucous surfaces, the last-named disease much more rarely involving 
the lymphatic glands ; there is usually itching in the yaws eruption ; 
there is no characteristic copper color in its eruptive features ; yaws 
does not affect the bones save in the continuity of long-standing ulcer- 
ation of the skin ; the subject of yaws is susceptible to indefinite auto- 
inoculation ; yaws though common in children is not inherited ; healthy 
parents may have infants seriously affected with frambesia ; lastly, the 
two diseases have been noted as of concurrence in the same person. 

Etiology. — The disease is endemic in certain tropical countries, 
occurring chiefly in the black races and especially among the filthy, 
though it is seen also among the whites. 

The disease is caused by a specific microbe — a rod-shaped bacillus — 
occurring singly and also in couplets and triplets, and being about 2 p. 
in length and 0.5 fi in breadth. It is readily cultivated in nutrient 
jelly, and is capable of transference, with production of yaws not only 
upon the skin of man, but also upon that of the lower animals, espe- 
cially the cat. 

Treatment. — The disease yields readily in the simpler cases to mild 
parasiticides ; in severe cases tonics are required internally, such as 
iron, quinine, and strychnine. 

The Prognosis is favorable save in broken-down subjects. 

PARANGI. 

Kynsey reports upon the nature of this disease, which is thus desig- 
nated in Ceylon, where it prevails. 

It appears to present mixed features of syphilis, land-scurvy, yaws, 
pellagra, lupus, leprosy, scrofula, and less severe disorders, existing as 
an endemic in certain provinces of the island. It is clear, from the 



686 NEW-GROWTHS. 

description of the symptoms recorded, that the nature of the disease 
has not been recognized. It was first described in 1868 by Loos, and 
is now regarded as due to numerous causes, such as malnutrition induced 
by impure food and water, wretched hygienic surroundings, and infection 
from the discharges from ulcers. 

There is, according to Christie, 1 an incubation-period of from two to 
eight weeks, followed by the appearance of an ulcer over any bony 
prominence — the initial sore. This period is succeeded by malaise and 
pyrexia, the premonitory fever lasting from two to eight days, and is 
followed by the exanthem, which appears first over the face, and later 
upon the body. This eruption may be vesicular, pustular, pustulo- 
tubercular, or squamous, superficial ulcerations forming which become 
crusted subsequently. Rupioid, furuncular, and psoriasiform features 
are common in the course of the malady. Condylomata may appear 
at the anus. Ulcerations succeed later of a more formidable character, 
involving the nose, palate, and cheeks ; the digits may be lost by gan- 
grene ; blebs occur ; pricking-pains are experienced ; there may be 
anaesthesia of some part of the surface, associated with bronzing and 
glazing of the skin. The patient may perish of some intercurrent dis- 
order or from exhaustion. The duration of the disease is said to be 
from two to eight years. 

Treatment has been successful with the cautious employment of 
mercury and potassium iodide, and strict observance of the rules of 
hygiene. 

DONDA NDUGU. 

Donda ndugu (" Brother ulcer," or "Ulcer that clings") is a disease 
existing in Central and Eastern Africa. Christie, 2 who first described 
it, believes it to be identical with that from which Livingstone suffered 
in 1870. 

The disease is confined to the lower extremities, and it occurs among 
the natives chiefly in the rainy season after a march toward the coast. 

Donda ndugu is characterized by the appearance of whitish papules 
springing from a boggy swelling, seen often near the toes, heel, or 
dorsum of the foot. When incised, an extensive, deep-seated slough is 
found beneath the healthy tissue, bathed in an ichorous discharge. 
Severe rapid-spreading ulcerations and death may ensue. Livingstone 
extracted the ova of a species of maggot from such lesions in his own 
person ; but Christie failed to discover them in his cases. 

The Treatment is local, by the use of antiseptics after incision. 

VERRUGA PERUANA. 

(Peruvian Wart.) 

This is a specific disease, both endemic and at times epidemic, oc- 
curring for the most part in the mountains of Peru, and communicable 
by inoculation. There is a prodromic febrile stage, followed by the 
appearance on the skin of maculo-tubercular, softish, tender, henii- 

1 See Anderson's Treatise on Diseases of the Skin. 

2 Ibid. 



PLATE XXIII. 




PrefungoicT Stage of Mycosis Fungoides. 

(From a painting.) 



MYCOSIS FUNGOIDES. 687 

spherical tumors, which may attain the dimensions of a large nut. 
Hemorrhagic effusions occur as a result of fissures in the epidermis 
covering the lesions, at times in coercible and leading to fatal anaemia in 
severe cases. The lesions may be few or numerous ; may occur on the 
several parts of the head and extremities (rarely on the trunk), and may 
eventually desiccate or break down into ulcerations. A fatal result may 
occur at any stage from hemorrhage, or the disease may be relieved 
in the course of a few months. It is said to attack whites more often 
and with greater severity than negroes. 

Hirsch l and others have described the disease, an outline of 
which is given by Crocker, who states that the mortality is from 6 to 
10 per cent, among the natives ; and from 12 to 16 per cent, among 
the whites, or, in epidemics, 40 per cent. Bacilli have been recog- 
nized, and may be the cause of the disorder. 

MYCOSIS FUNGOIDES. 

(Gr. fivKT/g, a mushroom.) 

(Granuloma Fungoides, Granuloma Sarcomatodes, Inflamma- 
tory Fungoid Neoplasm, Eczema Tuberculatum, Fibroma 
Fungoides, Lymphodermia Perniciosa, Sarcomatosis Gen- 
eralis. Fr., Lymphadenie Cutanee.) 

This disease was first described in 1814 by Alibert, as "Pian fon- 
goide." Its symptoms resemble that affection, though not in any way 
related to it. 

The disease is rare ; less than two hundred cases have been recorded 
in literature : but so many of these have been carefully observed and 
fully reported that all the symptoms of the disorder are fully established. 
An attempt has been made to distinguish between two forms. There 
is, however, but one. 2 

Symptoms. — For convenience in description the symptoms may 
be grouped roughly in three stages, which, however, do not always 
occur in regular succession, and of which the first and second may 
never be manifested. 

The so-called "Premycosic Stage " (Erythematous Period 
[Bazin]; Stadium Eczematosum [Kaposi]) is characterized by the 
occurrence of a series of cutaneous phenomena of different types, which 
have been described as resembling, if not identical with, eczema, lichen, 
erythema, pityriasis rubra, psoriasis, urticaria, furunculosis, and other 
congestive and inflammatory cutaneous affections. In a recent con- 
tribution based on a personal experience in thirteen cases and a review 
of the literature of forty-eight cases in which these early phenomena 
were described, we stated 3 that we believed, in common with a few 
other investigators, that these early dermatoses, though differing con- 
siderably in clinical type, have many characteristics in common, and 
are the varied expressions of a definite morbid process. The term Pre- 
fungoid, employed by Morrow, would better designate this stage than 

1 Handbook of Geog. and Hist. Pathology, vol. ii., p. 114. 

2 Cf. Max Walters' monograph, with sixteen illustrations. Stuttgart, 1899. 

3 Jour. Cutan.and Gen.-Urin. Dis., June, 1899. 



688 NEW-GROWTHS. 

the generally accepted term premycosic. The mischief is undoubtedly 
declared with the earliest pruritic symptoms, and the skin-eruptions in 
the early periods of mycosis should be considered as significant expres- 
sions of a general disease as the tumors themselves. 

The earliest phenomena vary greatly, and may imitate any of the 
above-named dermatoses. The most frequent lesions, however, are in 
the form of round or circinate, sharply defined, erythematous patches, 
usually characterized by scaling and by itching. These areas are com- 
monly from one to six centimetres in diameter, but may be of any size, 
and in rare instances (as in one of our cases) the redness and scaling 
may be universal. The lesions usually are dry ; but at times may be 
moist, crusted, or even the seat of small papules and vesicles. The color 
varies through the different shades of red, often combined with tints of 
brown or purple. As the lesions persist thickening and infiltration of 
the skin are noted, and the patches become more sharply outlined, more 
distinctly circinate in contour, and, by extending peripherally while 
clearing in the centre, begin to assume the gyrate and fantastic figures 
so characteristic of the disease. Itching is usually a pronounced feat- 
ure, but may be absent. The course of the lesion is capricious, even 
more so than in eczema. One or all of the patches may suddenly dis- 
appear spontaneously, only to return without apparent cause in old or 
new sites, and after intervals of days or months. Treatment, either 
constitutional or local, seems to have almost no influence upon the 
course of the lesions. This stage, during which the patches come and 
go, may last a few months or several years before the appearance of the 
more characteristic areas of infiltration. 

In what may conveniently be called the second stage, or Period of 
Infiltration (Lichenoid Period [Bazin, Vidal, Brocq, Fabre]), 
circinate, sharply defined, elevated plaques and nodules appear, either 
in the site of previous lesions or independently of them. The nodules 
are pea-sized or larger ; the infiltrated plaques are button-sized to palm- 
sized, or larger, sometimes extending over the greater portion of the 
chest, back, or abdomen. The color varies from a bright pink through 
varying shades of red and occasionally of brown or violet. The sur- 
face may be smooth or verrucous, or fissured and excoriated as the 
result of scratching. The pruritus is usually severe, but may be absent. 
The shape and career of these plaques are almost, if not quite, diag- 
nostic. They are circular or circinate, as a rule, and as a result of an 
extending periphery and clearing centre they are constantly changing 
in both site and contour, often moving over the surface in gyrate bands 
or lines, or assuming half-moon, crescent, horseshoe, kidney, or other, 
often fantastic and grotesque, shapes. Again, they disappear and re- 
appear without apparent cause, as do the lesions of the first stage. 
While in many cases these variations in site and form require several 
months for completion, cases not infrequently occur in which the whole 
aspect of the disease changes in a few days. In one of our patients 
the lesion assumed the form of a curious network of connecting, broad, 
flat-topped ridges, between which were corresponding valleys of nor- 
mally colored and apparently normal integument. As a rule, the lesions 
on disappearing leave no trace of their previous existence, but they may 



MYCOSIS FUNG OWES. 



689 



be followed by areas of more or less permanent pigmentation or of 
vitiligo. More rarely, circumscribed areas destitute of pigment and re- 
sembling leucodermatous patches, may occur in the skin where no pre- 
ceding lesion has been observed. The symptoms of this period often 
occur with, or may be replaced by, those of the preceding stage. The 
two periods together may last many years (fourteen in one case) before 
the appearance of tumors, though in exceptional instances they may be 
preceded by tumor-formation. 

In the so-called third, or Fungoid, Stage (Mycofungoid, Neo- 
plastic Period), which, in some instances is the first and only stage, 
the characteristic Tumors of the disease appear upon the face, scalp, 
chest, and other portions of the body. They are bean- to orange-sized, 




Mycosis fuugoides. 

or larger ; whitish, pinkish, pale, or dull reddish in hue, sessile or 
pedunculated, well rounded or lobulated and distinctly circumscribed. 
When developing from the plaques above described they may be quite 
flat. They may develop from any of the previously described lesions 
or from the sound skin. They occur upon all parts of the body, upon 
the palmar and plantar surfaces, the arms, the forearm, the thighs, the 
legs, the face, and the back. Often they are in various degrees pig- 
mented, showing purplish, brownish, or even black colors. They are 
usually painful, and may or may not be tender. When the tumors have 
attained maturity, and before involution has begun, their appearance, 
especially upon the face, is characteristic. Here they are smooth, 
moderately firm, globular, often lobulated, or sausage shaped, of a pecu- 
liar reddish hue, and when numerous produce a lepra-like deformity, 
closing the eyes in consequence of their size or weight, producing the 

44 



690 NEW-GROWTHS. 

leonine brow and the elephantiasic ear. In a case reported by one of 
us/ and illustrated in Fig. 84, the body of the patient was extensively 
covered with tumors of all sizes resembling those seen on the face. 

Like the other lesions of this disorder, the tumors may disappear 
spontaneously, while others appear ; or they may all disappear to return 
after uncertain intervals without known cause. As a rule, they leave 
no trace of their previous existence, though they may be followed by 
pigmentation or slight atrophy of the skin. Sooner or later some of 
the tumors degenerate, and lead to superficial ulceration, usually fol- 
lowed by papillary excrescences and mushroom-like growths of vary- 
ing sizes from which the disease obtains its name. At times they may 
be the seat of much more destructive ulceration, though with but few 
exceptions this destruction is limited to the new-growth, and even large 
fungoid and apparently deeply ulcerated tumors may completely dis- 
appear and leave no trace further than pigmentation and possibly a 
small atrophic scar. 

The general condition of the patient at first seems unaltered ; later, 
when the tumors ulcerate, exhaustion occurs and the victim usually 
dies as a result of febrile processes, of intercurrent disorders, of leuco- 
cytliEemia, of cachexia, or of pyaemia. When the tumors are many 
and ulceration extensive the appearance of the patient is repulsive in 
the extreme ; the exhalations from the body are in the highest degree 
fetid, and the difficulty of procuring asepsis, hygienic care, and comfort 
for the wretched sufferer is well-nigh insurmountable. Extirpation of 
the tumors is usually followed by recurrence, frequently with added 
malignancy. 

The superficial and deep lymphatic glands may enlarge, and this 
adenopathy, as in the case of the tumors, may subside to be replaced 
later by similar involvement of the same or other glands. Other com- 
plications of the disease are : pleuropneumonia, pulmonary tuberculosis, 
hemiplegia, nephritis, and erysipelas. 

The duration of the tumor-stage is brief compared with the others ; 
frequently death occurs within a few months, though it may be post- 
poned two or three years. 

Etiology. — The disease is more frequent in men than in women, 
often in those of unusual weight and size, and usually occurs between the 
thirtieth and fiftieth year of life, oftenest after the fortieth year, though 
in a few instances it began earlier, even in childhood. Though the 
cause of the disease is not definitely known, there can be little question 
to-day as to its infectious character. It is probably produced by specific 
micro-organisms, but direct evidence of contagion and successful cul- 
ture- and inoculation-experiments are wanting. 

Pathology. — The disease has been studied by many observers, 
including ourselves. While the reports of different investigators at 
first reading apparently vary widely, closer study of the recorded 
observations indicates that on the main points they agree. The early 
lesions show on histological examination dilatation of the vessels with 
often some endothelial proliferation, and a more or less dense cell-infil- 
tration that is usually limited to the upper part of the corium, except 

Edinburgh Med. Jour., 1883-1884, page 592. 



MYCOSIS FVNGOIDES. 691 

where it surrounds some of the deeper vessels in the forms of sheaths 
or " cuffs." Galloway and McLeod l describe in the early stages a con- 
nective-tissue cell-infiltration not only about the vessels, but also about 
the hair-follicles, the sebaceous glands, the muscles of the hair-pouch, the 
ducts of the coil-glands, and occasionally along the lymphatic spaces be- 
tween the connective-tissue fibres. They conclude that the characteristic 
infiltration may originate in the cells of any of these structures. The 
infiltration in some instances is diffuse, but sharply separated from the 
deeper parts of the corium by a horizontal line, and from the rete 
above by a narrow layer of connective tissue. In other instances the 
infiltration occurs in round or irregular areas, separated by bundles of 
normal connective tissue. Where the cells are most compact they are 
supported by a very delicate fibrous structure made up in part of elastic 
fibres. Degeneration of collagenous and elastic fibres occurs in the late, 
but not in the early, stages of the disease. The cells forming the infiltra- 
tion are in the main of the connective-tissue type, but in many cases they 
and their nuclei show the greatest diversity in size, shape, and staining 
qualities. Round, cuboidal, or irregularly shaped cells with little pro- 
toplasm and a deeply staining nucleus are numerous. Many of the 
irregular bodies are apparently fragments of cells. In many places the 
cells are so closely packed as to modify their shape and size. This mul- 
tiformity of the cells is apparently characteristic of the disease, and 
Unna believes that it is due to the result of two antagonistic processes 
constantly going on, that is, cell-multiplication and cell-destruction, 
and that many of these odd forms are nothing more or less than cell- 
fragments. Mast-cells, multinuclear cells, and giant-cells are seen in 
some lesions, but are absent in others. Mitotic figures are frequent. 
The papillae are enlarged, in places packed with cells, in others more or 
less oedematous, as also are portions of the subpapillary layer. The 
rete is everywhere hypertrophied, the interpapillary processes being 
elongated, broadened, and frequently branched. In places the cells are 
swollen and oedematous, with spaces between them. Mitotic figures 
here also are numerous, especially in the basal layers. 

As the lesions progress toward the tumor-stage the cells in the 
corium become more regular in form and size, and the rete becomes 
much thinner. In the fully developed tumors the rete is usually 
reduced to a few, sometimes but one, layers of cells, but in a few 
instances it dips down deeply into the growth in a way to suggest epi- 
thelioma were it not that these epithelial processes are very slender. 
Many of the tumors correspond closely in structure to sarcoma, others 
show the histological formation of granulomata. 

Numerous micro-organisms have been seen in the tissues, and some 
have been cultivated, but none has yet been demonstrated to have any 
pathogenic relation to the disease. Among them may be named strep- 
tococci in the capillaries of granulation-nodules, and staphylococci in 
cultures from blood. Other examinations of blood, of infected tissue, 
and of tumors were wholly negative as to the discovery of cocci. 

It is alleged that mycosis fungoides is a form of sarcoma. The facts, 
however, that fully developed tumors disappear spontaneously, and that 

1 Brit. Jour, of Derm., May and June, 1900. 



692 NEW-GROWTHS. 

in but few instances has involvement of viscera been reported in mycosis 
fungoides, should, without other minor differences, be sufficient to 
exclude the disease from the sarcoma group. In a few cases of mycosis 
fungoides changes in the deeper organs have been found similar to those 
which occur in leukaemia and pseudoleukemia, but no definite relations 
have been recognized between these conditions and the disease under 
consideration. There is a growing tendency among observers to class 
mycosis fungoides with the infectious granulomata. 

Diagnosis. — The age, weight, and often the protuberant abdomen 
of the patient are usually to be considered. In the early erythematous 
stages the disease is to be distinguished especially from eczema, psoria- 
sis, urticaria, erythema multiforme, and dermatitis exfoliativa. While 
a positive diagnosis cannot always be made at this time, in the 
majority of cases a careful consideration of the typical features 
just described will leave little doubt as to the nature of the 
disease. The circinate contour of the lesions, their spontaneous dis- 
appearance and reappearance, and the rebelliousness to treatment of 
.what appears to be a mild and superficial inflammatory process, are 
features not found to the same extent in any of the other dermatoses 
named above. Aside from the absence of these three marked character- 
istics in psoriasis there is much more thickening of the plaques and 
there are characteristic scales, while the situation, history, and other 
features of the lesions are usually sufficient for a diagnosis ; in moist 
forms of eczema the discharge and multiformity of lesions are both 
greater than in mycosis fungoides. 

When these early lesions of mycosis fungoides appear in irregular 
patches the diagnosis from eczema can be made only after they have 
been under observation for weeks or months. In those exceptional 
cases which begin as a generalized exfoliative dermatitis an early diag- 
nosis is not possible. 

After the appearance of infiltrated plaques, or of well-developed 
tumors in case the other stages are absent, the diagnosis is usually 
clear. The infiltrated areas, nodules, and smaller tumors may at 
times closely simulate leprosy ; but the history, the absence of areas of 
anaesthesia and other characteristics of leprosy, and the histological 
examination should clear up the diagnosis without difficulty. The 
tumors are distinguished from those of sarcoma by their history and 
career, and by their final formation of characteristic fungoid, super- 
ficially ulcerating masses. 

The Treatment is unsatisfactory. 

The pruritus and complicating dermatoses which may be present in 
the early stages may be treated locally with various soothing, protect- 
ing, and antipruritic applications (see treatment of eczema) according 
to the indications in each case presented. 

The comfort of the patient is to be secured by all measures, includ- 
ing anodynes in an advanced stage of the disease, and his strength 
should be supported by a generous diet and tonic regimen. Arsenic 
in full doses and by hypodermatic injection has been of apparent ser- 
vice ; Koebner reported one patient cured by this treatment. Locally 
ichthyol, bismuth oleate, and many other preparations have been of 



SARCOMA CUTIS. 693 

service in allaying the symptoms and retarding the progress of the 
disease. When the affection is generalized tepid baths are productive 
of great comfort ; the use of boric acid, resorcin, aristol, carbolic acid, or 
some similar agent is indicated by the fetor arising from the person. The 
ulcerating masses may be protected by a wet antiseptic dressing, or, 
after cleansing, dusted with the zinc stearate compounds, iodoform, 
aristol, or other powder, and protected by a proper dressing. Extir- 
pation of the tumors is proper when such a course will add to the com- 
fort of the patient. 

The Prognosis is unfavorable. The patient may survive from a 
few months to a maximum of fifteen years, the average being from two 
to four years. After the development of tumors the patient may live 
but a few months or at most two or three years. Three cases of re- 
covery are on record, one patient apparently relieved after an attack 
of erysipelas. 

SARCOMA CUTIS. 

(Gr. capZ, flesh.) 

Sarcoma of the skin is characterized by the occurrence, either as pri- 
mary or as secondary developments, of single or multiple, pea- to egg- 
sized and larger, pigmented and non-pigmented, cutaneous and subcu- 
taneous neoplasms having a marked inaptitude for ulceration but malig- 
nant in character, recurring after extirpation, and usually terminating 
fatally with involvement of the viscera. 

The term sarcoma, meaning a fleshy tumor, was originally employed 
by Virchow in the designation of this disease. 

Symptoms. — Cutaneous sarcoma is an uncommon affection, and its 
clinical forms are not always clearly defined. In general they may be 
divided into two groups, though transition-forms exist. 

(A) Melanotic Sarcoma, or Melano-sarcoma. — This is the more com- 
mon form. It may develop from a pigmentary nsevus that has been 
irritated, or from any pigmented point upon the integument, especially 
upon the dorsum of the hands and feet, the lower extremities, the geni- 
tal region, and the face — over the cheek or near the orbit, where it may 
originate from the choroid coat of the eye. In a few instances meta- 
static, sarcomatous deposits on the face have been preceded by a 
diffuse bluish pigmentation. 

Melanotic sarcoma may be of primary occurrence or may develop 
as a secondary deposit. The lesions are bean- to egg-sized, usually 
single or multiple, very firm or doughy, sessile or pedunculated, spher- 
oid or lobulated ; and varying in color from grayish brown to inky 
blackness. The epidermis may be discolored, thinned, and intact, or 
be ulcerated. The nodules are often surrounded by blackish puncta 
wdiich eventually develop into tubercles. The lesion or lesions may 
for a long time remain stationary, or they may rapidly be followed 
by generalization, as a result of local irritation, either by extension 
from a central point to adjacent tissue, or by transmission through the 
lymphatics to a distance from the primary nodule. 

In a case lately observed the left lower extremity of a middle-aged 
woman was studded with split-pea-sized to marble-sized, ink-black 



694 NEW-GROWTHS. 

masses from the ankle to the middle of the thigh. The larger were 
always centres of groups of similar pinhead-sized black nodules. The 
skin of the region affected was swollen, inextensible, inelastic, and as 
firm as sole-leather. The disease had extended from the ankle upward 
in the course of a few months. 

Melanotic sarcoma is one of the most malignant and rapidly fatal 
of all neoplasms. Therapy is unavailing ; and the prognosis is grave 
indeed, a fatal result usually occurring with rapidity after the occur- 
rence of generalization, and commonly w T ith visceral complications by 
reason of secondary deposits. 

Recent studies of Unna, Gilchrist, 1 and others indicate that malig- 
nant growths arising from pigmented moles are usually (if not always) 
carcinomatous rather than sarcomatous. 

Melanotic Whitlow (Hutchinson) is described as a chronic ony- 
chia, displaying pigmented spots, suggesting silver-nitrate stains at the 
edge of the nail-fold, where eventually a fungus tumor forms with 
increase of pigment until the nail is exfoliated, and the process becomes 
generalized. 

(B) Primary Non-melanotic Sarcoma. — This occurs in both localized 
and generalized forms. 

The localized variety of primary non-melanotic sarcoma is rare, and 
is seen chiefly in women. As in other sarcomata, it is often first recog- 
nized at a point where a nsevus or other warty growth has become irri- 
tated, usually on the extremities. At such a point there forms a firm, 
dull-whitish nodule, having nearly the hue of the normal skin, rarely 
vascularized, that may, after persistence without change for a variable 
period, break down by ulceration and become the seat of a fungous 
vegetation. Generalization of the process may result either spontane- 
ously or from accidental complications. 

The disease, when affecting the skin in multiple lesions, is character- 
ized by the appearance of several, usually at first isolated, pea- to nut- 
sized and larger, smooth, spherical, irregular, or lobulated cutaneous or 
subcutaneous tumors. They may or may not at first be attached to the 
epidermis above and to the deeper structure beneath, but they eventually 
contract such adhesions. Between them the skin may not be involved. 
In uncomplicated cases at this period the conspicuous features of these 
lesions are : (a) their whitish color, due to envelopment in an unaltered 
epidermis ; (6) the history of a relatively rapid development, as distin- 
guished from fibromata, epitheliomata, gummata, and lupous tubercles, 
(c) the speedily declared systemic results of the growth. 

Later, the skin between the lesions becomes swollen, infiltrated, 
painful ; and, even before the tubercles desquamate, enormous tume- 
faction and redness of an erysipelatous type may affect the internodular 
tissue. In this way an entire limb, only one portion of which is the 
seat of tubercular growth, may attain an elephantiasic size, ulcerate at 
one or more points, and pour out an offensive secretion as a consequence 
of ulceration of the inflamed integument. 

The disease is both rapid in course and malignant in type. In a 

1 Jour. Cutan. and Gen.-Urin. Dis., March, 1899. 



SARCOMA CUTIS. 695 

few weeks or months the nodules or tumors of sarcoma coalesce, degen- 
erate by ulceration, and participate in the process going on in the in- 
flamed and excoriated skin where they are implanted. Death results 
either from exhaustion, intercurrent fever, or sarcomatous involvement 
of one or of several viscera. By the same process the skin-lesions may 
be the product of metastasis from the lymphatic glands or the viscera. 

The disease occurs in this form over the chest, the extremities, and 
the genitalia, though all parts of the skin have been invaded. 

Idiopathic Multiple Pigment-sarcoma (of Kaposi and others) 
owes its coloring to cutaneous hemorrhages and not to a pigment-de- 
posit. It occurs chiefly in male subjects (from forty to sixty years of 
age) who have been laborers, whose hands and feet become the seat of 
an oedema, accompanied by pruritus and other subjective sensations. 
Later, brownish, bluish-red, or dark-purplish spots appear, out of 
which develop pinhead- to pea-sized nodules, gradually increasing in 
volume, discrete, tender, and often grouped. They may be the seat of 
lancinating and radiating pains. As they multiply a lardaceous infil- 
tration progressively involves the depth of the integument, until an 
elephantiasic condition is produced, a hand, a foot, or an entire limb 
becoming of cartilaginous hardness, bluish in tint, and covered with a 
smooth, mammillated, squamous, or rugous envelope, which may be 
also the site of tumors of considerable size. These tumors are fewer in 
number and smaller in volume as they spread from the distal to the 
proximal parts of the limb. They may be sessile, pedunculated, and 
grouped, but they are always of a deep-bluish or violaceous tint. 

These growths may remain for a long time stationary ; or they may 
be entirely resolved, the patient apparently securing complete recovery. 
Very rarely they ulcerate or exhibit slight erosions. At times they 
are covered with or surrounded by telangiectases, or by tissue exhibit- 
ing infiltration of blood. When the mucous membranes are involved, 
points, patches, disks, or infiltrations of a dusky-reddish or a bluish 
shade appear on the inner side of the gums, the lips, the tonsils, or over 
the palate ; and there is visceral involvement with lymphatic and 
vascular changes. The usual signs of physical exhaustion ensue, with 
fever, dysenteric symptoms, haemoptysis, and marasmus. The disease 
may last only from three to five years, but a duration of fourteen years 
has been recorded. Post mortem tumors have usually been recognized 
in the viscera. Only a few infantile cases have been recorded. 

Remarkable instances of complete recovery from this affection are 
multiplying. A patient with the hands completely relieved was shown 
at the International Dermatological Congress in London, in the year 
1896, Kaposi having verified the diagnosis. A patient rapidly recov- 
ering from the same disorder is under our observation. It is doubtful 
if this condition be a true sarcoma — in the sense in which this term is 
generally accepted. 

Recurrent Fibroid of the Skin (Hutchinson), beginning usually 
in the lower extremities, and tending to slow extension, to rapid and 
persistent recurrence, and to ulceration and formation of fungous tumors, 
with ultimate marasmus, is set down by Crocker as a rare form of 
spindle-cell sarcoma. 



696 



NEW-GROWTHS. 



Multiple cutaneous and subcutaneous tumors are reported in leu- 
kaemia and pseudoleukemia. Some of these are apparently sarcomatous 

in nature while others evidently 



Fig. 85. 



mycosis 




Sarcoma: spindle-cells visible in sections of 
cutaneous nodule removed from a sarcomatous 
patient. (About X 300.) 



should be classed with 
fungoides. 

The Etiology of sarcoma is 
unknown. According to Babes, 
sarcomata are frequently congeni- 
tal, and are not rarely found in 
early youth upon the eyelids, the 
extremities, and the genitalia. 

Pathology. — Sarcoma of the 
skin may be primary, but is proba- 
bly more often secondary to the 
disease in deeper organs of the body. 
Histologically, it is a connective- 
tissue growth, made up largely of 
round- or spindle-cells, and corre- 
sponds closely to the structure of 
sarcoma in other parts of the body, 
the spindle-cell being somewhat 
more frequent than the round-cell 
type. Other mixed types, as fibro-sarcoma, angio-sarcoma, or lympho- 
sarcoma, are seen occasionally. The most common type recorded is the 
melanotic sarcoma which has been described as developing from pig- 
mented moles or warts. Recent investigations prove that some, proba- 
bly the majority, of these growths should be classed with carcinoma. 

In the so-called " idiopathic multiple pigment-sarcoma" of Kaposi 
the pigmentation is due entirely to hemorrhage and the blood-slowing 
which follows. The growth is highly vascular, containing many newly 
formed vessels, the walls of which are very thin and often are made up 
of the cells of the tumor. 

Fordyce l describes several cases of localized angio-sarcoma of the 
skin in which the single tumor was identical histologically with the 
generalized sarcoma of Kaposi. 

The Diagnosis rests upon the history, symptoms, and microscopical 
examination of the new-growth. Sarcoma should not be confounded 
with fibroma, epithelioma, gumma, or lupous nodules. 

Treatment is unsatisfactory. Surgical ablation of these tumors is 
apt to be followed by their speedy return. 

Koebner's injections of arsenic (usually Fowler's solution, 2 to 4 
drops in 1 to 2 parts of distilled water, repeated every second day for 
months, with gradual increase of the dose) seem to have proved success- 
ful in two cases. 2 Wende 3 reports a case improving under this treatment. 
Arsenic, potash, and ergot, internally, and salol, camphorated naphtol, 
aristol, and bismuth subnitrate, locally, have secured only transitory 
benefit. Successful results, but also several deaths, are reported from 

1 Amer. Jour. Med. Sci., Aug., 1900. 

2 Berlin, klin. Woch., 1883, No. 2. 

8 Jour, Cutan. and Gen.-Urin. Dis., 1898, p. 205. 



CARCINOMA. 697 

inoculation with cultures of the streptococcus of erysipelas. Favorable 
results have been reported in a few instances by Coley and others from 
the injection of the combined toxins of this streptococcus and of the 
bacillus prodigiosus. In the majority of cases these measures are 
unsuccessful. 

The Prognosis is unfavorable, a fatal issue occurring in most cases. 

CARCINOMA. 

(Gr. naptdvog, cancer. ) 

The term cancer has been employed both loosely and definitely in 
the designation of malignant cutaneous tumors. Every cancer of the 
skin is, according to some authors, necessarily both alveolar and epithe- 
liomatous in structure ; while others distinctly recognize forms of cancer 
which are not epithelial. In these pages, for the sake of retaining a 
convenient clinical distinction, the term carcinoma, or cancer, is limited 
to malignant growths of epithelial origin. 

EPITHELIOMA. 

(Epithelial Cancee, Caecinoma Epitheliale, Rodent Ulcee. 
Ger., Epithelialkeebs ; Fr., Canceoide.) 

Symptoms. — Three clinical varieties of epithelioma are recognized 
— the superficial, the deep, and the papillary. They are practically no 
more than varying phases of a single pathological process. 

Superficial, or Discoid, Epithelioma is usually first displayed upon the 
sound skin in the form of one or of several pinhead-sized papules, flat 
infiltrations, disks, or nodosities of a dull-yellowish, reddish, grayish, 
or dirty wax-like hue. The growth may also have its origin in pre- 
viously existing skin-lesions which are both numerous and different 
from one another. Among the latter symptoms may be named : fissures 
and excoriations (especially those long teased by caustic applications) ; 
warts, nsevi, acneiform and molluscoid lesions ; and the dry or greasy 
epidermal scales often seen at the orifices of sebaceous glands in the 
faces of the aged. The outline of the newly developed growth as a 
consequence varies, being roundish, linear, or irregular. As a result of 
accident or traumatism (especially scratching and picking, which the 
history of a large proportion of all cases includes) there forms a super- 
ficial excoriation, which may be covered with a sero-sanguineous crust 
after the desiccation of its scanty and ichorous secretion. In the prog- 
ress of its development it is often noticed that new foci of disease appear 
in the immediate vicinity of the first, represented by subepidermic 
indurated nodules, or superficial " pearls " resembling milia, whitish and 
lustrous, with marked tendency to vascularization, exfoliation, and 
superficial ulceration. 

Rodent Ulcee (Jacob's Ulcee, Ulcus Exedens, Noli-me- 
Tangeee, Canceoid Ulcee). — The characteristics of this form of 
superficial epithelioma are a roundish, fissured, or slightly angular con- 
tour, and a reddish or reddish-brown, irregular, granulating, and mam- 
millated floor, covered with a thin, translucent, viscid serum, which, in 



698 NEW-GROWTHS. 

drying, suggests the effect of a varnish over the part. The edges of 
the ulcer are clean cut, indurated, everted, usually well attached, and, 
seen in horizontal profile, irregularly indented. The symptoms are 
slight at first ; the lymphatic ganglia and general health being unim- 
paired. Its site of election is the face, particularly the eyelids, nose, 
temples, and lips, though the genitalia, the hands, and the feet may be 
affected. Of two hundred and fifty cases collated by Heurtaux, in one 
hundred and ninety the face was attacked. 

Some English writers still describe the rodent ulcer as distinct from 
epithelioma, chiefly by reason of its individual peculiarities. Patho- 
logically no distinction can be established between the two. The clin- 
ical features upon which this distinction is based are : the slow or 
intermittent development of rodent ulcer ; its tendency to destroy, as 
it extends, all the tissues within reach ; its failure to implicate the 
system by secondary deposits or metastases ; its rounded and often 
widely everted edges, or, better, lip, often distinctly vascularized ; its 
gouged floor exhibiting unequal levels ; its slight tendency to granula- 
tion ; and its feeble or negative attempts at repair. All these symp- 
toms are those of epithelioma, if one chooses to employ that term in its 
large and proper sense. The rounded or oval excavation, often exceed- 
ingly clean cut, at times with a corded and whitish rim, producing, 
little, if any, pain, is characteristic of the rodent ulcer, yet in its exten- 
sion it may exhibit all the symptoms of a deep epithelioma. 

Under the title " Crateriform Ulcer," Hutchinson 1 describes a form 
of epithelioma distinguished chiefly by rapidity of invasion. Its 
onset is by the formation of a roundish or conical mass which rapidly | 
exhibits ulceration, a central crater forming with exceedingly dense 
walls. 

The subsequent course of the lesion varies, its evolution being gen- 
erally slow and accomplished in years. Sometimes having attained a 
maximum of size, the ulcer, if unmolested, long persists without appre- 
ciable change. In other cas'es the base cicatrizes and the epithelioma 
completely exfoliates, leaving an outlying linear ulceration which may 
persist or spread. In yet other cases, after a persistence of from ten to 
twenty years, the ulcer may spontaneously close and the disease be at 
an end. Sometimes the ulceration is very superficial and slowly 
spreads in circles, segments of circles, or in irregular gyrate outlines, 
the older portions healing and cicatrizing while the border advances. 
Such lesions may cover considerable areas of the body and closely 
resemble the serpiginous lesions of syphilis and lupus. In many 
cases the papillomatous element is marked. To this form of super- 
ficial discoid epithelioma the name Paget's Disease is sometimes 
applied, as the process is practically the same as that which attacks 
the nipple and breast. Finally, any one of the destructive and malig- 
nant cancerous processes may be awakened, and the epithelioma be 
thus transformed from the type of the superficial to that of the deep 
variety of the disease. 

Deep, or Tubercular, Epithelioma. — This variety may originate in the 
manner already described, or may be from the first characterized by 

1 Transactions of the London Pathological Society, 1889, p. 275. 



CARCINOMA. 699 

its specific features. It commonly begins by the formation of round- 
ish, very firm, pea-sized nodosities closely set in the skin and subcu- 
taneous connective tissue, or be thus situated and well projected from 
the surface. In the course of months and years these nodules develop 
to form a nut- or even a small egg-sized tumor, roundish, dark reddish 
in color, and delicately vascular on its surface. This tumor may be 
a deep flattish or globoid development within the skin ; or be a well- 
defined nodule attached to it ; or (and this is a common form) be a 
dense, thick, flattened plaque, a centimetre or more in diameter, its 
walls steeply descending to the sound skin on either hand or mode- 
rately everted ; its centre depressed by atrophic changes ; its surface 
shining, waxy, pinkish, or red, with ramifying capillaries. " Satellites" 
may form in its vicinity. 

Degeneration of these forms produces in the course of time an ulcer 
either like that described above, or one which deeply and destructively 
encroaches upon the tissues beneath. In advanced cases the latter 
ulcer is irregular in contour, with a clean-cut, everted, indurated lip ; 
eroded and "gouged," hemorrhagic and granulating floor; thin, viscid 
secretion which is foul and purulent at times when the resulting destruc- 
tion is rapidly accomplished ; and a deep attached base Avhich may be 
perforated by a crateriform exulceration extending down to or through 
muscles, fasciae, cartilage, and bone. The lymphatic ganglia become 
simultaneously involved, and a general cachectic condition is established. 
Death may ensue from marasmus, exhaustion, or hemorrhage in the 
course of several months or from one to three years. 

Papillary Epithelioma. — The cancer in this variety assumes the form 
of a malignant papilloma. In these cases a pedunculated or sessile, 
narrow or broad-based, smooth-capped, or spongy and verrucous vege- 
tation is attached to the skin upon which it forms. It may originally 
be as small as a pea, but usually it increases considerably in volume, 
being not rarely pigeon's-egg- and turkey's-egg-sized. The surface is 
either dry, reddish yellow, smooth, and lustrous ; exfoliating, and se- 
creting an offensively smelling sanguineous or translucent fluid ; or is 
moist, granulating, filamentous, and intermingled with hairs, as when 
it occurs upon the bearded cheek. Degeneration occurs later, fissures 
forming first ; subsequently there appear superficial, and finally deep, 
ulcers which ultimately assume all the features of the epithelioma 
described above. 

In some cases the epithelioma forms a soft, hemispherical, small 
nut- to egg-sized tumor, which upon pressure discharges numerous 
convoluted plugs, composed of epithelium, fatty masses, and a purulent 
secretion. The bases of these soft masses are remarkable for the ease 
with which they can be curetted and thus radically removed. 

A careful study of well-marked cases of papillary epithelioma indi- 
cates clearly that while ulceration often results, the centre of the mass 
breaking down and furnishing a typical cancerous excavation, with 
hard and rounded or oval border, uneven base, irregular granulating 
floor, and offensive discharge, the picture may be wholly different. 
Occasionally the superficial process extends widely over the brows, 
cheeks, and chin, interspersed with raised cicatriform areas, suggesting 



700 NEW-GROWTHS. 

that ineffectual attempts had been made to check the disease by sur- 
gical measures. These apparently atrophic disks, mingled with vas- 
cular, florid, fungiform, pyriform, and oddly shaped outgrowths, are 
really cancerous infiltrations of the type of discoid epithelioma. They 
may be seen gluing the lobe of the ear to the cheek, or everting the 
lower lid, even when superficial papillary vegetations are the predomi- 
nant features of the disease. 

Epithelioma of the skin occurs also with multiform features, almost 
as numerous as the several different lesions from which a cutaneous 
cancer may take its origin. 1 Thus, a wart, a "button," a vegetation, a 
crack, an erosion, may result in a fissure that bleeds easily and refuses 
to heal. After months or years there forms an epithelioma, assignable 
to one of the clinical varieties described above. In other cases there 
may be a number of greasy scales upon the skin-surface resembling 
those seen in well-marked seborrhoea sicca ; and in one or two spots 
the removal of these scales offers to the eye a superficial erosion 
implicating the derma, bleeding freely, and, when undisturbed, crusting 
and slowly spreading under the crust rather than healing. In yet 
other cases a thin pellicle of apparently loosened epithelium, looking 
like a papery crust, is found, when removed, to cover three or more 
shallow ulcers, unexpected and hidden from view by the tenacious 
pellicle which had protected them and beneath which they had indo- 
lently and painlessly developed. 

These varieties or types of epithelioma may coexist in different por- 
tions of the same integument, or the one may develop from the other, 
a malignant papillary growth springing from a superficial or a deep 
cancerous infiltration. Familiar examples of the disease are seen upon 
the eyelids and contiguous portions of the nose ; the cheek and the 
lower eyelid, the latter being often drawn into ectropion by a cicatri- 
form bridle or band ; the nose or lip and adjacent mucous or osseous 
tissue ; and the glans and prepuce where the vegetating forms are of 
more frequent occurrence. The vast destruction wrought by the widest 
development and consequent degeneration of epithelioma is sufficiently 
recorded in the annals of both medicine and surgery. A woman sixty- 
four years of age was exhibited at the clinic, in the centre of whose 
face an ulcerating epithelioma had left a wide chasm, after destroying 
three-fourths of the nose and upper lip, and the hard palate with all 
the upper teeth and the antrum. The bones at the base of the skull 
were exposed. This case illustrated well the occasional remarkable 
tolerance by the system of the profoundest encroachments of epithe- 
lioma. She was then digesting and assimilating food with fair profit, 
and suffered chiefly from pain. She did not die until several months 
had elapsed, and then only as the result of hemorrhage from an ulcer- 
ative opening into one of the large arteries. 

Cancer of the Head. — In this region of the body nearly three- 
fourths of all cancers of the skin are recognized. Upon the brow, 
the ala3 of the nose, the temples, cheeks, chin, scalp, or other part, the 

1 Cf. Fordyce : " Clinical and Pathological Observations on some Early Forms of 
Epithelioma of the Skin/' N. Y. Med. Jour., June 9 and 23, 1900. 



CARCINOMA. 701 

disease may begin either upon or beneath entirely normal skin, or in 
that which has pathologically been changed. The origin of the disease 
is usually ascribed to the picking, scratching, or shaving over a seba- 
ceous wart in an old man ; or in similar traumatisms of acneiform, 
seborrhoeic, or furuncular lesions in either sex. In other cases the der- 
matologist, consulted with reference to some other ailment of the skin, 
can recognize, in persons of the age most liable to such accidents, one 
or several pinhead-sized or larger milium-like nodules, clustered about 
the temples or the nose, that indicate the site of the awakened epithe- 
liomatous change. The disease progresses slowly, spreading super- 
ficially along the alse of the nose in irregular lines, in more complete 
centrifugal outline over the temple and brow ; almost symmetrically 
over the tip of the nose, and with odd indentations of contour in the 
dense integument immediately in front of the tragus of the ear. The 
vegetating forms are more common on the brow, scalp, and chin ; the 
" rodent-ulcer " type, over the temples and cheeks. The more super- 
ficial varieties in any part of the face may slowly be converted into the 
deeper. The flattened, egg-sized disks of infiltration are more common 
on the cheeks and chin. 

The devastation produced by malignant cancer is nowhere more con- 
spicuous than in the face. Cartilage, bone, muscle, and entire organs 
melt before its ravages with astounding readiness. Within a period of 
two years a circumscribed flat epitheliomatous infiltration, limited for 
many months to one cheek, may spread to the point of destroying the 
ear, eye, and inferior maxilla of one side of the face, opening into the 
larynx and oesophagus, and not producing a fatal result until the jugular 
vein of the same side is opened by ulceration. 

Cancer of the Lower Lip, far more common in men than in 
women on account of the tobacco-habits of the former, may arise either 
as a minute lobule or as a circumscribed thickening on or near the 
vermilion border, usually of one side, or as a linear, narrow, and shal- 
low excoriation, often protected by a thin crust, extending well along 
the mucous edge of the lower lip that is in contact with the upper 
when the two are lightly approximated. Later, the lip may be the 
seat of a defined tumor, small nut- to egg-sized, that may deeply in- 
volve the entire thickness of the lip, encroach upon the chin, loosen 
the teeth, destroy the gums, larynx, pharynx, tongue, and maxilla, and 
eventually produce one of the formidable and remediless chasms of the 
lower part of the face already described. 

Cancer of the Genital Organs is submitted to the surgeon 
more frequently than to the dermatologist. The glans penis, the 
clitoris, and the prepuce are occasionally the seat of a warty variety ; 
but the scrotum, labia, thighs, mons veneris, and abdominal walls, as 
well as the parts first named, may be involved in the superficial or the 
deep form of cancer. In persons of cleanly habits the superficial 
variety of epithelioma may persist in the genital region as indolent and 
innocuous as upon the face ; but where filth is permitted to accumulate 
about the part (lochial, menstrual, catarrhal secretions ; pus, urine, 
feces, etc.) the spread may relatively be rapid. The ulcer is then deep, 
seated upon an indurated and very tender base, and has the steep, 



702 NEW-GROWTHS. 

punched edge and hemorrhagic floor of the rodent ulcer. Ulceration 
may, later, open the rectum, vagina, corpora cavernosa, perineum, and 
deep perineal fascia, resulting in vast destruction that proves fatal by 
exhaustion of the forces of the aged patient. 

Cancer of the Extremities, particularly of the back of the 
hand, is at first usually papillomatous, or of the flat, superficial form. 
It may appear upon the left hand of right-handed patients. Its prog- 
ress is indolent, and when properly treated is much less liable to grave 
ulceration than epitheliomata in other situations. In special regions, 
especially on the lower extremity, where the force of gravity generally 
aggravates any ulcerative process, there may result caries, necrosis, 
fistules, loss of phalanges, etc. 

Cancer of the Mucous Surfaces may be primary or be second- 
ary in origin. The mucous lining of the oral and nasal cavities, of the 
vagina, the rectum, and the balano-preputial sac may thus be involved, 
either by extension of the disease from the neighboring cutaneous sur- 
face or by primary involvement of the mucous tissue. The most 
important, by reason of statistical frequency, is cancer of the tongue 
and buccal membrane, often having its origin in the leucoplasic stria- 
tums, plaques, or thickenings, known as " smokers' patches," ichthyosis 
lingua?, psoriasis linguae, etc. A pinhead- to pea- or bean-sized super- 
ficial excoriation is usually the first lesion to which attention is attracted, 
reddish in color, granulating, tender, and not often very painful ; or the 
beginning is a shallow fissure at the edge or on the tip of the tongue or 
on the mucous face of the lower lip, its long axis commonly at right 
angles to that of the organ upon which it forms. Beneath with more 
or less rapidity (as a rule slowly) dense induration occurs, lancinating 
pains dart from the affected region toward the ear or along the jaw, the 
submaxillary and other glands become tumid and tender, deglutition pain- 
ful and in severe cases well-nigh impossible ; or from the nasal membrane 
the disease extends toward the palate, pharynx, or larynx, ulceration, 
when it occurs, opening up a vast chasm which represents all these 
cavities. In the vagina and the rectum a cancerous change may begin 
with merely a thickening of the surface of the mucous membrane lead- 
ing in the course of time to a superficial and later to a deep ulcerative 
process ; or, as in cutaneous epithelioma, the papillary form may be repre- 
sented in vegetations, cauliflower-shaped, filiform, or simply warty and 
mammillated, that eventually degenerate and furnish the most formida- 
ble of destructive results. 

Etiology of Epithelioma. — The essential causes of cancer are 
unknown, though there can be no question that mechanical, chemical, 
and other local irritations are often immediate excitants of its patho- 
logical processes in the predisposed skin. In this way the excoriations, 
warts, nsevi, and other lesions named above, though not in themselves 
cancerous, may become the original sites of the disease. In this way, 
too, the irritation produced upon the lips of the smoker by his pipe or 
tobacco ; the local disorder about the inner canthus of the eye result- 
ing from occlusion of the lachrymal ducts ; the frequent teasing by 
caustic or other substances of the wart on an old man's hand ; and 
other agencies disturbing the balance between waste and repair, aided 






CARCINOMA. 



703 



at times by senile atrophic changes, may result in the development of an 
epithelioma. The possibility of the transmission of cancer by heredity 
has almost ceased to obtain credence in the light of modern pathology, 
yet Broca reports sixteen deaths from cancer in one family, and Fried- 
erich a congenital epithelioma in the child of a cancerous woman. 

The disease is eminently one of advanced life, being most frequent 
after the fortieth year, and a pathological curiosity in childhood. 
Kaposi reports one case at the tenth year. Only about 30 per cent, 
of all cutaneous cases occur in women, a fact possibly explained by the 
relative infrequency of the action of local irritants in those who are 
not subjected to the exposures incidental to the trades and laborious 
occupations of life. These figures, however, relate only to cancer of 
the skin, since, when cases of cancer of the breast and of the uterus 
are included, the proportion of the sexes affected is almost exactly 
reversed. 

In favor of the local origin of cutaneous epithelioma is the clinical 
fact of the excellent general health of most patients in the earliest 
stages of the malady ; while those affected with syphilis and tubercu- 
losis are usually exempt. The theory that carcinoma is due to a 
specific parasite and is, therefore, infectious and contagious, is gaining 
ground. No parasite has yet been demonstrated, since the protozoa- 
like bodies Avhich Darier and others described in cancer-cells have been 
demonstrated to be forms of cell-degeneration. 



Fig. 86. 




Epithelioma (vertical section) : a, d, cones of the rete projecting downward, between these 
' are seen atrophied papillse (b) ; ate, d, and other points are " nests " of epithelium; c, atrophied 
stratum corneum. (After Kaposi.) 

Pathology. — All epitheliomata have their origin in preexisting 
epithelium. The old idea that they originated from connective tissue 
j has been disproved. The essential feature of all forms of epithelioma 
j| is proliferation of epithelium and its growth into the deeper tissues, 
where it is not normally found and where its presence causes secondary 
i inflammatory changes. Two pathological types of epithelioma are of 
j interest to the dermatologist, the lobulated and the tubular. 

In the Lobulated form the interpapillary processes of the rete send 

| down prolongations which subdivide and branch in all directions, the 

branches intercommunicating and giving off buds and processes which 



704 NEW-GROWTHS. 

may form new centres of growth. The origin of the growth may be 
traced to the interpapillary processes or to the epithelium of the seba- 
ceous glands, coil-glands, or hair-follicles; but more frequently the 
source cannot be determined absolutely, since the band connecting the 
growth with its starting-point may have been destroyed by ulceration. 
On the other hand, the glands and follicles may be involved second- 
arily. Attempts have been made to classify epitheliomata according to 
the structure from which each originates, but there seems to be no good 
ground either clinical or pathological for such distinction. The branch- 
ing processes form variously shaped lobules, and the cells composing 
them assume, as the result of pressure, many shapes. Usually, how- 
ever, the outer layer of a lobule is a row of cylindrical cells within 
which are cuboidal prickle-cells, which toward the centre are under- 
going cornification, the centre itself being composed of horny stratified 
cells. Thus, the structure of a lobule from without inward corresponds 
closely with that of the normal epidermis from within outward. Some- 
times the prickle-cells within the lobules show no tendency to cornifica- 
tion. In places the lobules are compressed into globular masses having 
concentric layers like an onion. These bodies are the epithelial " nests," 
" globes," or " pearls." The centre of such nests not infrequently shows 
colloid, fatty, or granular changes. In rare instances calcification of 
the lobule occurs. 

The connective tissue of the part into which the growth has pene- 
trated surrounds and supports the lobules, and may remain almost nor- 
mal, or be thickened and infiltrated with round cells, or its fibres may 
be mixed with epithelial cells ; it contains blood-vessels, none of which 
penetrates the lobules. In some cases the epithelial growth proves 
greatly irritating to the surrounding tissues, exciting in them marked 
inflammatory processes. Fordyce believes the inflammation may be 
due in part to a pus-infection, and in one case, by using Gram's method, 
he demonstrated staphylococci in the inflamed tissue. 

In the Tubular variety of epithelioma the epithelial elements form 
freely anastomosing, cylindrical processes which extend vertically, 
horizontally, and at various angles through the cutis and often into the 
subcutaneous tissue. The cells are smaller than in the lobular variety 
and do not, as a rule, undergo cornification or form " nests." The 
outer row of cells may be cylindrical and stain deeply, and as the tubu- 
lar processes may assume shapes highly suggestive of gland -formation, 
this variety of epithelioma is supposed by some observers always to 
originate in the epithelium of a coil- or sebaceous gland. Largely 
owing to the ease and rapidity with which the starting-point or con- 
necting-band may be destroyed by ulceration, it is often impossible to 
demonstrate the origin of the processes, but the investigations of 
Darier, Pollitzer, Fordyce, and others have led to the belief that the 
growth originates rarely in the sebaceous glands, but frequently in the 
rete or in the epithelium of the coil-glands and hair-follicles. 

Tubular epitheliomata are, as a rule, less malignant and less rapid 
in their course than are those of the lobular type. Transitional forms 
are seen, however, which tend to show that the shape and mode of de- 
velopment of the processes depend as much upon the accident of loca- 



CARCINOMA. 705 

tion and surrounding tissue as upon the character of the epithelium 
from which they originate. Rodent ulcer — which some authors de- 
scribe under a separate head — is pathologically a tubular epithelioma. 

Diagnosis. — Epithelioma is to be distinguished from lupus vulgaris 
approximately by the age of the patient, the latter disease rarely 
appearing after the thirty-fifth year where there is no scar or a history 
of its earlier existence. Lupus is, at an earlier period of its career, 
more diffuse than epithelioma ; its elementary forms are more dis- 
tinctly groups of individual lesions than a homogeneous aggregation ; 
its ulcers are more often bordered by outlying non-ulcerative papules ; 
furnish a more puriform discharge ; and, most distinctive of all, are 
never walled about by the firm, densely indurated, often everted lip 
of the epitheliomatous ulcer, opening out often to a sound peripheral 
integument. The peculiar and often characteristic odor of the cancer- 
discharge is absent in lupus. 

From syphilis, epithelioma is to be distinguished : first, by the age 
of the patient, syphilis being decidedly a disease of early and middle 
life ; second, by the far greater relative rapidity of the syphilitic pro- 
cess, exception always being made of tertiary gummatous ulcers upon 
the lower extremities persisting for years when there are both lack of 
internal treatment and of local support ; third, by the history of the 
disease in each particular case ; and, fourth, by the characteristic 
syphilitic features always present in infected individuals, including 
multiplicity of lesions, typical cicatrices, contour of ulcers (that of 
epithelioma is less often either reniform, horseshoe-shaped, or cres- 
centic), character of discharge, and general absence of pain. A very 
important point to note is a marked tendency to reparative cicatriza- 
tion in old syphilitic ulcers, partly due to exhaustion of the infec- 
tive poison, partly to the influence of an insufficient but yet modifying 
treatment. This tendency is exceedingly rare in epithelioma, which is 
often, while syphilis is rarely, a malignant disease. 

Epithelioma of the genitals is not to be confounded with chancre, 
gumma, or syphilitic tubercles of that region. The peculiarities of the 
consequent adenopathy in each case ; the lancinating pains of cancer ; 
its much more prolonged duration ; and its occurrence in an aged subject, 
with the general history of the case, will usually point to the truth. 

Sarcoma is characterized by its far more rapid evolution, the tumors 
often attaining their maximum of development in the course of a few 
months ; by its occurrence by predilection in earlier life ; by its inapti- 
tude for ulcerative degeneration ; and by its marked tendency to multi- 
plication in contiguous or in distant portions of the body. 

The warts, nsevi, excoriations, and seborrheic lesions, from which 
epitheliomata often take their origin, cannot be determined as having 
such a tendency before the cancer has attained some development. 
Every such persistent and long-irritated lesion on the person of a male 
subject of advanced years should be regarded with suspicion. 

Treatment. — No internal treatment for cancer of the skin is known 
to exert the slightest influence upon the growth. 

The topical treatment of epithelioma is by excision, erasion, or 
destruction of the growth. The first is performed by surgical ablation 

45 



706 NEW-GROWTHS. 

with a bistoury, after which one of the plastic operations may be 
required for either complete covering of the wound or relief of the 
resulting deformity. The second is applicable only to the less for- 
midable growths, and is performed with the aid of a dermal curette. 
The third is effected by the use of caustics. The removal of smaller 
epitheliomata, of the face especially, with the aid of a dermal curette, 
should generally be followed by the thorough application of the milder 
caustics, such as silver nitrate in crayon. 

Destruction of smaller cancerous tumors of the skin may be per- 
formed with the aid of caustics, of which potassium hydroxide, in stick 
or in solution, is perhaps the most valuable, as its destructive action 
may be controlled by the topical employment of acids, and it is fol- 
lowed by less pain than are some of the other chemical agents. Other 
caustic substances employed for a similar purpose are : zinc chloride, 
Vienna paste, silver nitrate, arsenical paste, resorcin, fuchsin, and pyro- 
gallol. The latter is highly recommended by Kaposi, not only because 
its application is unproductive of pain, but also because it does not 
attack sound tissue. It is used in an ointment of 10 per cent, strength. 
All such pastes and ointments should be spread upon cloths, and be 
applied for from three to six days. Opiates may be required, in the 
case of several of these agents, to relieve the consequent pain. 

Among the formulas used for caustic purposes are the following : 



R Creasoti, ^ss; 15 

Acid, arsenios., gr. iv ; 

Opii pulv., gr. ij 



26 

13 M. 



Sig. For employment upon circumscribed surfaces. [Kaposi.] 

Marsden's paste, also employed as a caustic, is made by combining 
equal parts of gum arabic and arsenious acid with water sufficient to 
make a softish paste. By Robinson 1 it is preferred to others, and is 
applied on rubber plaster. 

Cosmos paste, as modified by Hebra, is prepared as follows : 



B Acid, arsenios., gr. yj ; 

Hydrarg. sulphuret. rub., 3ss ; 2 

Unguent, aq. ros., ^ss ; 15 

Sig. Arsenical paste for external use, with caution. 



40 
M. 



The method of its application is as follows : the paste is spread over 
a thin sheet of lint to the thickness of a knife-blade, and the lint is then 
cut to a shape and size corresponding with those of the tumor or ulcer 
to be destroyed. After its close apposition with the surface to be 
attacked the lint and paste should be covered with gutta-percha or 
other impermeable tissue, and a compress laid over the whole. In 
twenty-four hours the dressing is removed, the parts washed clean, and 
the same application renewed. By the third or the fourth day the 
destruction of the cancerous growth is usually complete, and the parts 
are ready for an emollient poultice, which should be applied for the 



1 " Treatment of Cutaneous Malignant Epitheliomata," Internat. Jour, of Surgery, 






CARCINOMA. 707 

three or four days during which separation of the slough occurs. 
The simple ulcer left is to be treated on general principles. The 
danger of arsenical poisoning is here reduced to a minimum ; the treat- 
ment being very effectual where patients consent to the delay as to time 
and to the severe pain which it occasions. 

The thermo- and galvano-cautery may also be often advantageously 
used for destruction of the growths. The advantages of the thermo- 
cautery are : the transitory character of the induced pain ; the coal-like 
dressing left upon the attacked surface ; and the elegance of the result- 
ing scar. Both measures find their highest value when employed after 
incision or erasion. 

Whatever method be employed, thoroughness is essential in attack- 
ing all portions of the new-growth ; and it is well to encroach some- 
what upon the unaffected contiguous structure. The subsequent dress- 
ings should be made with simple or carbolated unguents, to which one 
of the salts of morphine may be added in case of continuous pain. 
The eschar usually separates in the course of a few days, leaving a 
simple granulating wound which may soundly cicatrize, and the 
epithelioma be thus radically relieved. In other cases the disease reap- 
pears in the ulcer or cicatrix, or, by recurrence of cancerous nodules, in 
the previously sound integument. Even after these recurrences 
prompt destruction of the new-growth may finally be successful. 

But little confidence is placed upon any external treatment which 
does not effect complete destruction of the neoplasm. Yet there are 
those who highly esteem some of the , procedures which are less radical 
in their aim, and which it is proper to mention here. 

Leveque, 1 Vidal, 2 Bergeron, 3 Euthyboule, 4 and others claim large 
success in the treatment of epithelioma by potassium chlorate. Locally, 
the part is frequently touched with a saturated solution of the salt in 
glycerin and warm water, after which a simple ointment-dressing is 
applied. Vidal administers also the same drug internally in doses of 
1J drachms (6.) in syrup and water before meals. It is possible that 
any remedial effect obtained from such measures should be attributed 
to the fomentations employed. Latterly, benzole and pyoktanin-blue 
have been reported as valuable topical applications to small-sized 
epitheliomata. 

Injections of solutions containing cupric sulphate, iodine, alcohol, 
I acetic acid, silver nitrate, sodium chloride, and hydrochloric acid 
I have been practised, it is claimed, with some success ; certainly at 
I times with fatal results. This method is unquestionably inferior to 
j others described above. 

Prognosis. — In general, the prognosis of cutaneous cancer is grave. 
The relative degree of gravity largely will be proportioned to the variety, 
? form, size, career, and complications of the growth in each case. The 
variety in which only " pearls " form in the skin is the most benign, 
as the lesions are usually isolated, and may, when unirritated, undergo 
spontaneous exfoliation. In other cases the disorder for from fifteen 
i to twenty years seems to make no progress of any sort. The malignity 

1 Glasgow Med. Jour., 1881. 2 Loc. cit. 

3 Bull. Acad, de Med., Paris, 1873. * These de Paris, 1877. 



708 NEW-GROWTHS. 

of a cancerous growth is usually proportioned to the quantity of epi- 
thelium as compared with the connective tissue present ; the more 
abundant the latter, the more favorable the prognosis. Naturally, also, 
the deeper and the more destructive the growth, the fewer are the 
chances of ultimate recovery. Excessive pain and adenopathy are 
unfavorable symptoms in any case. Koch x gives statistics of the 
results of operations, at the Erlangen Clinic, for the removal of 
epitheliomata of the lower lip, in one hundred and thirty-one patients 
exhibiting primary lesions. One hundred and fifteen of these were 
for the time "cured"; four had speedy relapse; and three were, at 
the date of writing, suffering from recurrence of the disease. 

PAGET'S DISEASE. 

(eczematoid epitheliomatosis of the nlpple, malignant 
Papillary Dermatitis, Cutaneous Psorospermosis.) 

This disorder was first described in 1874, by Paget, 2 and has since 
attracted the special attention of a number of English, French, and 
American observers, including Thin, Duhring, Malassez, Darier, Wick- 
ham, and others. 

At the onset the disease suggests an eczematous involvement of the 
areola of the nipple, usually of one breast only, in women between 
forty and sixty years of age. According to Besnier and Doyon, the 
earliest change is without question a choking of the lacunas of the 
nipple with corneous cells, and this either without the operation of any 
known cause or as a consequence of a localized eczema, a gal actor rhcea, 
or other irritant. When early recognized the surface is intensely red 
and granulating, exuding copiously a clear viscid secretion, and pro- 
ducing subjective sensations of heat and burning, with intense or with 
moderate itching. The definition is distinct, the tissue is indurated, 
and the tenderness and pain are usually well marked and distressing. 
A conspicuous feature of the disease is the circumscribed infiltration 
of the skin and subcutaneous tissue, which on palpation suggests a 
large-sized coin or button let into the substance of the areola and sur- 
rounding parts. 

When the disease has progressed to this point a cancerous infiltra- 
tion of the breast is usually recognized, at least after its removal, 
though even with great care it may not always be possible to distin- 
guish it before ablation of the gland. Crocker, however, holds to the 
belief that the disease of the nipple may endure for years without 
resulting retraction and development of scirrhns of the breast. The 
French recognize three stages, that in which the disease is limited, re- 
spectively, to the nipple, the areola, and the breast, the latter, of course, 
succeeding but not replacing the earlier. In all cases there is no at- 
tempt at repair ; and when abandoned to its course the ultimate result, 
after five to eight or more years, is a profound ulceration with destruc- 
tive effects most noticeable in the region of primary invasion, the entire 

1 Centralbl. f. Chir., 1881, No. 40. 

2 St. Bartholomew's Hospital Reports, 1874, p. 87. See also the paragraphs in this 
treatise devoted to this subject under the title of Eczema. 



CARCINOMA. 709 

breast having become cancerous. Cases of Paget' s disease affecting 
other parts of the body have been reported. In such cases the process 
is identical with that of superficial discoid epithelioma described on a 
preceding page. 

Pathology. — Darier and Wickham, in a series of papers published 
during 1889 and 1890, attempted to show that this disorder was to be 
included in a list of morbid processes which they described under the 
title of " Psorospermosis/' a group of affections of parasitic origin. But 
later investigations have shown that the so-called " psorosperms " are 
in fact simple alterations of epithelium that may be recognized in other 
affections as well as in Paget' s disease of the nipple. 

In the earlier stages the histopathology is that of a chronic derma- 
titis. Epithelial proliferation and thickening progress, however, and 
in the later stages the structure is that of a discoid epithelioma. 

Diagnosis. — There are few cases in which the raw and exuding sur- 
face may be mistaken for an eczema. The latter, when occurring upon 
the surface of the breast and of the nipple, is far more common during 
earlier periods of womanhood than after the fortieth year, and is seen 
chiefly among those giving the breast to sucklings. Eczema is never, 
under any circumstances, capable of producing in this region the 
characteristic button- or large-coin -sized induration beneath the deep- 
red, raw, granulating surface of the cancerous infiltration. 

The Treatment of Paget's disease should always have in view the 
possibility of cancerous involvement of the gland that usually occurs, 
though a number of cases are on record in which relief by other than 
radical measures was secured. Caustics should never be employed ; all 
irritants are to be avoided. Soothing applications, as in corresponding 
stages of eczema, the pastes, zinc and calamin lotions, diachylon and 
other soothing salves, are indicated and often prove serviceable. The 
employment of parasiticides meets with little favor now that the psoro- 
spermosis theory of the disease is abandoned. Mercurial lotions fol- 
lowed by powders of aristol or hydronaphtol (1 : 100), and a weak 
ointment of pyrogallol or of iodoform are also extolled. Complete era- 
sion of the morbid tissue may be successful, but ablation of the entire 
breast is demanded in most of the typically developed cases. 

The Prognosis is not always grave. Cases are reported as relieved 
by local measures, which are always worth a judicious trial ; but inef- 
fectual measures may permit involvement of the breast eventually call- 
ing for ablation of the entire gland. 

CANCER OF THE CONNECTIVE TISSUE. 

This is rare as a primary cutaneous manifestation, but appears gen- 
erally as secondary to a cancerous involvement of other organs, as of 
the female breast. It is termed also Scirrhous, Hard, Fibrous, or 
Lenticular Cancer. It occurs either upon the skin covering a 
breast which has previously been transformed into a cancerous mass, 
or as a cutaneous relapsing lesion after extirpation of the latter. Its 
symptoms are pea- to bean-sized, densely firm, shining nodules, vary- 
ing in color ; or a more or less diffuse infiltration of the skin, of similar 



710 



NEW-GROWTHS. 



characteristic hardness, associated often with hyperemia of a purplish- 
red shade. 

Cancer en Cuirasse. — When the cancerous infiltration is widely dif- 
fused and densely indurated, involving a large portion of the integu- 
ment of the thorax, the condition is termed by the French cancer en 
cuirasse (Fig. 87), a title first given by Velpeau. The malady is 
striking in its peculiarities, and in the highest degree serious. The 
integument of a large portion of the chest, usually more in front, but 
also behind, and even a part of the anterior abdominal wall, is con- 
verted into a dense, leathery envelope, often so compressing the chest- 
wall as seriously to impede respiration. The edges of the infiltration 
are poorly defined save at the lines where tongue-like prolongations 
(languettes) of dull-reddish hue indicate the advance of the scirrhous 

Fig. 87. 




Cancer en cuirasse, chiefly involving the right side of the chest. 



process over the skin. The lymphatic circulation is obstructed, the 
glands enlarge, and, what is almost pathognomonic of the disorder, the 
upper extremity, especially the forearm, usually of the side chiefly in- 
volved, becomes enormously swollen and cedematous. The nipple may 
or may not be retracted ; the breasts, one or both, are firmly bound down 
to the chest-wall by the cuirass of dense skin, hard, smooth or rough, 
shining, and either reddened in dull hues or of normal tint, here and 
there traversed by vessels, and breaking down into ulcerations, usually 
first about the nipple, but also elsewhere. The process is one of the more 
rapid of the scirrhous metamorphoses of the body, as a fatal result is 
usually reached in a few months, though years have in some cases 
elapsed before death resulted. One of our patients, an unmarried woman 
with breasts in the virgin state, perished in the course of a few months, 



CARCINOMA. 711 

the cancer having originated in the skin. Milium-like masses, as large 
as grains of wheat, undergoing fatty degeneration in the centre and 
readily expressed like comedones, are occasionally present. 

We have had several cases of this disorder under observation, two 
being made the subject of a paper, 1 with illustrations of the clinical 
appearances and morbid condition of the tissue. One of the patients 
was a man. An instance of widely disseminated lenticular cancer of 
the skin (illustrated by portrait), described by Morrow, 2 occurred in a 
healthy-looking woman as a secondary phenomenon after removal of 
primary cancer of the breast. Whether the nodules be, as to cutaneous 
manifestations, primary or secondary, the symptoms are generally the 
same. The lesions are closely set, shining, firm, reddish papules, infil- 
trations of a dull-reddish hue, miliary and pigmented deposits, tubercles 
varying in size, subcutaneous nodules, and secondary results in the way 
of formidable ulcers, crusts, and fungous growths. 

The prognosis is serious. 

Pathologically, the several forms of carcinoma above described are 
epitheliomatous, since the fibrous stroma always contains, in the centre 
of narrow alveoli, a relatively small number of epithelial bodies. The 
growth is usually slow of development, but in the end is accompanied, 
as are other cancerous tumors, by adenopathy, pain, and ulcerative 
changes, which induce an inevitable cachexia. As with the other varie- 
ties, relapse after extirpation is common, and the prognosis is propor- 
tionately grave. 

Tuberose Carcinoma is a rare manifestation of the disease, occur- 
ring in the form of multiple, firm, peanut- or egg-sized, roundish nodules, 
which break down by ulcerative processes into deep losses of tissue. It 
is frequently accompanied or followed by cancerous involvement of 
other organs. It occurs chiefly upon the face, hands, arms, and chest, 
though also upon other portions of the skin of persons of advanced 
years, either as a primary or a secondary cancerous manifestation. 
Gurnard 3 reports a cancer of this variety, remarkable for the smallness 
of the existing nodules, which varied in size from that of a hempseed 
to that of a pea. They covered the entire thorax, the back, and the 
right arm ; and had here and there broken down into ulcers. One of 
the latter was as large as the hand. 

Melanotic or Pigmented Carcinoma is that form in which both 
the epithelium and connective-tissue framework of the cancer are richly 
supplied with blood-vessels, and, probably, as a consequence of trans- 
udation from the latter, with an abundance of pigment-granules in 
groups and clusters. These growths usually begin as hempseed- to 
pea-sized, single or numerous, soft or dense nodules, which may develop 
in time into tumors of considerable size, and which are stained in 
various shades from a grayish-brown or a slate color to a dead black, 

1 Amer. Jour. Med. Sci., March, 1882. 

2 Jour. Cutan. and Yen. Dis. . June, 1884, p. 1. 

3 Union Med., February 5, 1881. 



712 NEW-GROWTHS. 






the pigment being occasionally displayed irregularly in streaks or bands 
over the surface of the growth. They occur over any portion of the 
surface, often upon the extremities and the genitals, starting frequently 
from benign pigmentary lesions, such as nsevi and moles. Anatomically, 
the pigment is found to be deposited both between the cells and in the 
protoplasm of the cells themselves. 

In a few instances the disease is limited to single melanotic growths 
of this character. The cancer is apt to develop into the papillary form, 
furnishing thus fungoid vegetations which have a noteworthy tendency 
to degenerate into ulcers. Often such verrucous masses are seen sur- 
rounded by grayish or blackish papules, or by a diffuse cancerous 
infiltration of the integument ; they also exhibit irregular pigmentation 
of the surface. The disease often appears in the viscera, in the form of 
disseminated cancerous nodules, each highly vascular, and exhibiting 
in varying quantity granules of pigment. The growth has usually a 
relatively rapid course and malignant career. Relapses are frequent, 
the amount of pigment usually increasing with each relapse. 

Recent investigations (Cf. melanotic sarcoma) indicate that the 
majority if not all of the malignant pigmented growths which spring 
from moles and nsevi, and which in the past have been considered to be 
sarcomatous, are in fact instances of pigmented carcinoma. 

Endothelioma of the skin has been reported in a few cases. In 
the three cases reported by Spiegler, 1 and in the three cases collected 
by him from literature, numerous tumors, varying in size from a pin to 
an orange, were located on the scalp. In some of the cases pea-sized 
tumors were seen also upon the face, neck, back, and chest. The course 
of the growths was comparatively benign. In Fordyce's case 2 a pea- 
sized tumor formed at the border of a lupous scar on the forearm. The 
histological structure of these growths is that of a small-cell epithe- 
lioma, except that the cells are grouped about dilated blood-spaces, and 
their origin from the endothelium of the blood-vessels can be demon- 
strated. 

1 Arch. f. Derm. u. Syph., 1899, Bd. 1., S. 163. 

2 Amer. Jour. Med. Sci., August, 1900. 



CLASS VII. 
SENSORY DERMATO-NEUROSES 



A large number of skin-diseases are more or less dependent on 
neuropathic conditions, and could probably be classed as sensory, motor, 
vasomotor, or trophic dermato-neuroses. Morris 1 and Leloir, 2 and a 
few others attempt such a classification ; but in the large majority of 
these dermatoses the neuropathic element is not so well understood as 
are some other features according to which most authors classify these 
affections. In this chapter are considered only the sensory dermato- 
neuroses, that is, those disorders in which there is disturbance of sensation 
without other recognized changes in the skin. 

These purely sensory dermato-neuroses are commonly described under 
four headings : hyperesthesia, anaesthesia, dermatalgia, and paresthesia 
(including pruritus). 

Bronson 3 calls attention to the fact that cutaneous sensation is complex 
and made up of a number of elements which he describes as common 
sensation (or mere subjective feeling), including the sense of pain ; the 
sense of temperature ; the sense of touch, including the pressure-sense 
and the sense of contact ; and a special sense of a higher order, which 
is exercised in feeling for or of a definite object, and which he terms 
the sense of Pselaphegia. This sense includes and is dependent 
upon the preceding elements, and is ranked with the special senses of 
seeing, hearing, and smelling. Any one of the above-named senses 
may be exaggerated, defective, or perverted, while the others remain 
normal, or all may be involved simultaneously. 

HYPERESTHESIA. 

(Gr. vwep, above ; ala&Tjcic, sensibility. ) 

Hyperesthesia is an exaggerated sensitiveness to external impressions. 
In this condition the abnormal sensations are aroused by contact with 
an external body, and do not arise spontaneously, as in dermatalgia 
and in paresthesia. The distinction between these conditions may 
often be difficult to recognize, since two or more of them may coexist ; 
or the hyperesthesia may be so excessive that the slightest unrecognized 
current of air is sufficient to produce a marked sensation. Finally, in 
some forms of hyperesthesia abnormal sensations may result from 
irritation due to mental or emotional causes. It is evident that this 

1 Diseases of the Skin. London, 1898. 

2 Twentieth Century Practice, vol. v. 

5 Morrow's System, vol. iii., p. 725 ; and N. Y. Med. Kecord, Oct. 18, 1890. 

713 



714 SENSORY DERMATO-NEUROSm. 

last type of hyperesthesia can be differentiated with difficulty, if at all, 
from paresthesia. 

Cutaneous sensation may be exaggerated as a whole, but the senses 
most commonly involved are those of contact and common sensation, 
including the sense of pain. In mild cases there is merely an unusual 
sensitiveness to contact with foreign bodies, such as the clothing, but 
in severer forms the light touch of a feather or slight currents of air 
over the skin may be almost intolerable. In the condition known as 
Hypekalgesia the sense of pain is greatly exaggerated, while the 
sense of touch is diminished. As a result, the slightest contact with 
an object causes great pain, but the nature of the object causing the 
pain is not recognized so distinctly as in health. In some instances it 
is the temperature-sense alone that is involved, as a result of which 
the surface is exceedingly sensitive to cold, or, more rarely, to heat. 

Hyperesthesia, involving one or all of the senses mentioned above, 
may be mild or severe, and may be limited to very small areas, as in 
tabes or leprosy ; to certain regions or to one side of the body, as in 
hysteria ; or it may include the entire surface, as in disease of the 
cord, in neurasthenia, and in other disorders of the nervous system. 

The causes of hyperesthesia are found in various functional and 
organic disorders, central or peripheral, of the nervous system. 

In connection with the hyperesthesie may be mentioned a condition 
which cannot be considered pathological in itself, though it is often 
dependent upon pathological states. Reference is made to the unusual 
development and acuity of the touch-perception, or sense of pselaphegia, 
as a result of which contact with a foreign body gives the perceptive 
centres a more delicate and complete impression of that body than 
would normally be obtained. This unusual sensitiveness of the touch- 
perception is seen frequently in the blind, and may even be cultivated. 
It occurs also in the hypnotic state ; in intoxication from alcohol, or 
from cannabis indica ; in hysteria and some other mental and nervous 
disorders ; and in conjunction with the other forms of hyperesthesia. 

Treatment is that of the nervous disorder upon which the hyper- 
esthesia depends. 

DERMATALGIA. 

(Neuralgia Cutis.) 

In this morbid state the integument becomes the seat of painful 
sensations, which may or may not be associated with a hyperesthetic 
condition. This disorder is much more frequently partial than general, 
being in the larger number of cases a local expression of some disease 
of the nervous centres or tracts. It is observed usually in middle life, 
and in women more than in men. Its symptoms vary in severity from 
a slight burning to a state of torture that defies description. In charac- 
ter the pain is differently described as comparable to that produced by 
friction, incision, penetration, contusion, or burning of the integument, 
as also to the passage over the part of streams of very hot or of cold 
water, or the electric current. With this there is commonly associated 
an undue sensitiveness to contact with foreign bodies. The skin pre- 
sents no objective signs of disease. The disordered sensations may be 



HYPERESTHESIA. 715 

limited to the scalp, the region of the spine, or the palmar and plantar 
surfaces. In the latter situation it is often significant of some ob- 
scurely developed systemic disease, such as syphilis, rheumatism, or 
locomotor ataxia. In a middle-aged woman a persistent dermatalgia 
of the interscapular region was associated with confirmed gastric dys- 
pepsia. In other cases the disorder is dependent upon disturbance of 
the uterine function. It is occasionally observed as one of the rare 
signals of the occurrence of the menopause. 

It is to be noted that the severe dermatalgia associated with dis- 
orders of the uterus in women is occasionally succeeded by a cutaneous 
lesion. In a middle-aged dysmenorrhceic patient under observation a 
pea-sized hemorrhagic bulla appeared over the forehead after several 
weeks of frontal suffering. Buck 1 also reports dermatalgia of the 
brows and wrists in a young woman who had frequently miscarried, 
followed by recurrent formation of a vesicle which accomplished its 
career of rupture, crusting, and erosion in a stadium of from five to 
seven days. 

Diagnosis. — The disease is to be differentiated from hyperesthesia 
of the skin, with which it frequently is associated and from which it 
often cannot be distinguished with certainty, as it is not possible always 
to exclude slight sources of external irritation ; and further the diagnosis 
must be based largely upon the observations and statements of the 
patient. Painful affections of deeper parts, muscular, nervous, apo- 
neurotic, and visceral, must also be excluded. Severe pain limited 
strictly to the skin of the lumbar region, with hyperesthesia, may pre- 
cede the occurrence of perinephritic abscess. 

The Treatment is to be directed to the disorder of which, in the 

great majority of cases, the dermatalgia is merely a local symptom. 

Quinine, the salicylates, iron, arsenic, and zinc phosphide are often 

indicated. Temporary relief, however, may be afforded by the local 

application of a rubber bag filled with very hot or very cold water ; 

: sometimes by an alternation of the two, each for a few moments at a 

time. Sponging the part with very hot water is also useful, continued 

for longer periods, and followed by swathing in cotton-batting covered 

with Lister protective. In some cases the anodynes also may be used 

1 topically with advantage ; especially cocaine, opium, aconite, belladonna, 

j or stramonium in oily combinations. In some cases relief is had by 

; painting the parts with Squibb's mercuric oleate and morphine. The 

skin should generally, in the interval of application, be protected by a 

: dusting-powder ; and the clothing worn next the skin should be of an 

j unirritating character. 

Erythromelalgia is a term given by Mitchell to a condition in 
, which the fingers or toes are the seat of burning or aching pain fol- 
lowed by areas of redness. Other observers report cases occurring in 
connection with multiple sclerosis, tabes, myelitis, meningitis, traumatic 
neuroses, and other nervous disorders. Mitchell and Spiller 2 found a 
peripheral neuritis in one case. 

1 Phila. Med. and Surg. Eeporter, Jan. 18, 1881, p. 677. 

2 Ainer. Jour. Med. Sci., January, 1899- 



716 SENSORY DERMATO-NEUROSES. 



ANESTHESIA. 

(Gr. a, privative ; aiodqcig, sensibility. ) 

In cutaneous anaesthesia one or all of the elements of cutaneous 
sensation may partially or wholly be lost. 

Analgesia, or insensibility to pain, may exist while the tactile 
sense remains unimpaired, or the reverse may be true. Thermo- 
anesthesia may alone be manifested, and sometimes is limited to heat 
alone or to cold alone. A curious illustration of this occurred in the 
person of a leper, whose hands were in all parts sensitive to the prick 
of a lancet and to contact with heated substances ; yet who exposed 
them for hours without protection to an atmospheric temperature of 
ten degrees below zero without even slight discomfort. 

The tactile sense is involved more frequently than in hyperes- 
thesia, and usually is absent in all cases of anaesthesia. It, however, 
may be retained unimpaired with loss of one or all of the other elements 
of cutaneous sensation, as sometimes occurs in anaesthetic leprosy or 
syringomyelia. The failure to appreciate some one or more properties 
(such as form, size, weight, density, and smoothness or roughness) of 
foreign bodies may be psychical in origin. 

Illustrations of cutaneous anaesthesia are furnished in the anaesthetic 
patches of leprosy, which may or may not exhibit textural skin- 
changes ; centric and eccentric paralyses ; syphilitic, hysterical, and 
ataxic disorders ; partial or complete anaesthesia of artificial production ; 
the several toxic narcoses ; traumatism of nerves by pressure, wound, 
or contusion ; the local anaesthesia induced by cold, frigorific mixtures, 
and substances capable of benumbing the sensitiveness of the skin ; 
coma, of whatever origin; and a number of idiopathic cutaneous dis- 
orders, including several of the atrophies, scleroderma, and morphoea. 

PARESTHESIA. 

In paraesthesia there is a perversion of sensibility, as a result of 
which a given stimulus produces a sensation different from that which 
it would produce in health. One or all of the elements of cutaneous 
sensation may be involved. Contact with a warm object may give a 
sensation of cold or of pain. Derangement of the tactile sense may 
give erroneous impressions of the size, weight, roughness or smooth- 
ness, firmness, or other qualities of an object. Many other perversions 
of sensation occur, all dependent upon central or local disorder of the 
nervous system. Sensations may be delayed for some seconds after 
contact, or may persist after the latter has ceased. 

There may be an error of location, as when the patient refers the 
point of contact to the wrong place or to the wrong side. The paraes- 
thesia may be largely or wholly subjective, and frequently gives rise to 
the sensation of heat or cold, formication, tickling, dripping or pouring 
of liquids of various temperatures, etc. 



PARESTHESIA. 717 

PRURITUS. 

(Lat. prurire, to itch.) 

Symptoms. — Pruritus is a common form of paresthesia which is to 
be distinguished not only from prurigo, a rare disease of the skin 
already described, but also from the symptomatic sensation of itching 
which is occasioned by a number of cutaneous disorders, such as 
eczema, scabies, and the dermatoses produced by pediculi. 

Ilebra was first to recognize the independent character of the dis- 
ease here considered ; but it is to be regretted that he did not give to 
it a name distinct from that which is also applied to a symptom com- 
mon to several maladies of the skin. 

Pruritus is characterized by a sensation of itching not produced 
originally by cutaneous lesions. It may be general or be partial. In 
either form it begins usually by a tickling, pricking, crawling, or itch- 
ing sensation in the skin, which solicits the sufferer to rub, press, scratch, 
or otherwise irritate the affected integument. It usually occurs by 
accesses in the day or the night, much more often the latter, occasion- 
ally both ; and these accesses most frequently occur under the immedi- 
ate stimulus of some internal or external cause. Thus, moral emotions, 
a draught of cool air, the warmth perceived when in bed, the pressure 
of clothing, and often the substances applied externally with a view to 
the relief of the pruritus, suffice to determine a crisis. However firmly 
the sufferer may determine to avoid injury to the person, in well-marked 
cases the impulse to scratch becomes well-nigh irresistible and in the 
highest degree tormenting. From the milder, the patient will thus fre- 
quently be teased to inflict the severer injuries upon the skin. Brushes, 
combs, coarse cloths, and even metal instruments are employed in severe 
cases for the purpose of assuaging temporarily the local distress. 

The objective cutaneous symptoms which may be presented are all 
secondary, and invariably result from self-inflicted injury. In some 
cases they do not appear, the statements of the patient being the sole 
basis for the recognition of the disease. This absence may be the con- 
sequence of unwonted self-control, or of the mildness of the malady, 
or of the transitory character of the lesions produced. Thus, the skin 
may be reddened during a nocturnal paroxysm under the manipulation 
of the sufferer, and the transitory hyperemia disappear in the daytime 
when the skin is submitted for inspection. Not rarely, however, the 
integument resents the treatment to which it is subjected, by displaying 
wheals, hypersemic blotches, reddened papules, excoriations, charac- 
teristic " scratch-lines," and the minute blood-crusts which indicate 
that the papillary layer of the derma has been reached and slightly 
torn. Dermatitis in varying degrees, and even eczema, may result, and 
still further add to the subjective distress. Skins that for years have 
been the seat of a persistent pruritus leading to traumatisms of the epi- 
dermis frequently show smaller or larger areas of deep pigmentation. 

Cases are reported by Leloir and others in which a pruritus was fol- 
lowed by a dermatitis not due to traumatism, and persisting for con- 
siderable periods of time or until relieved by treatment directed to the 



718 SENSORY DERMATO-NEUROSES. 

condition of the nervous system. These cases are called by the French 
Neurodermia, or Neurodermatitis, and are probably due to vaso- 
motor or other neurotic disorders. 

Senile Pruritus is a term often loosely applied to any form of the 
disease occurring in the aged, in whom it is very common. In the 
large majority of cases, however, careful search will disclose causes 
identical with those found earlier in life. Among the most common of 
these causes are : defective digestion, metabolism, assimilation, and 
elimination, with the resulting hepatic, nephritic, circulatory, arthritic, 
and neurotic disorders so frequently seen in those advanced in years. 
Senile pruritus proper is that form of the disease due to atrophic and 
degenerative changes in the skin and other tissues of the aged, and is 
practically remediless. 

Pruritus Hiemalis is considered at the close of this chapter. 

The localized forms of pruritus, albeit the abnormal sensation is in 
them limited to certain regions of the body, may occasion fully as much 
distress as those in which a larger part of the integument is affected. 
They are of more frequent occurrence than the generalized forms. Pru- 
ritus of the anus, of the scrotum, of the vulva, of the vagina, of the 
scalp, of the nose, of the mouth, of the axillae, are all localized forms 
of the disease, two or more of which may coexist or may develop in 
succession. 

Pruritus Narium is a frequent symptom of irritation of the Schnei- 
derian membrane. It is thus a common precursory or an attendant 
phenomenon of rose- or hay-asthma ; and in some individuals announces 
the systemic effect after ingestion of opium and its alkaloids. It occurs 
also in children as a result of pediculosis of the scalp. It may result, 
further, from the irritation awakened by intestinal parasites. 

Pruritus Genitalium is often an exceedingly severe and dis- 
tressing affection. As the parts in question are apt to be rubbed and 
scratched in efforts to secure relief of the itching sensation, there may 
be produced orgastic effects and pollutions, the moral results of which 
are degrading. The scrotum, the labia majora and minora, the penis, 
the clitoris, and the adjacent cutaneous and mucous surfaces may be the 
seat of the pruritus. Search should always be made in these cases for 
ascarides of the rectum or of the vagina, for saccharine and albuminuric 
urine, and uterine or ovarian affections. A perverted sexual hygiene 
may lie at the root of these disorders. In severe cases the violence 
with which the parts are attacked suggests frenzy on the part of the 
patient, who at times is never content until the scrotum or other parts 
are bathed in blood. The thickening, erosions, and excoriations of the 
regions attacked are conspicuous features of the disease. 

Pruritus Ani. — This is a disorder of adults of both sexes, and it 
may coexist with pruritus of the genital region. There is usually noc- 
turnal exacerbation. The anus may become infundibuliform from in- 
duration ; its mucous surface excoriated ; its cutaneous borders seamed, 
puckered, eroded, and fissured. It is often complicated with, because 
the origin of, an eczema the lesions of which reach upward over the 
coccyx or forward to the genital region over the perineum. Hemor- 
rhoids, fistula in ano, ascarides, chronic prostatitis, rectal impaction 



PARESTHESIA. 719 

and fissures, proctitis, unnatural practices, gout, alcoholism, albumin- 
uria, or diabetes may each be responsible for its occurrence. 

Pruritus Palmje et Plants is a rare form of this disorder, in 
which the itching is limited to the palms and soles. It may complicate 
gout, malaria, hyperidrosis, and asthma. 

Pruritus Linguae is reported in a few instances. It usually is 
due to a central neurosis, to glycosuria, or other systemic disease. 

In all severe forms of pruritus cutaneus the general health per- 
ceptibly fails. Whether the prolonged insomnia arises from nocturnal 
exacerbations to which there are but few exceptions ; or from the per- 
version of nutrition incident to the continuous teasing of the nervous 
system ; or yet from the hypochondriacal state into which some patients 
are plunged by their sufferings, such an issue is often to be expected. 
It is, in fact, a complication that may merit, as much as the disease 
itself, the attention of the physician. 

Etiology. — The causes of pruritus are numerous, and the necessity 
for the discovery of the particular cause in each patient often makes the 
largest demands upon the practitioner. The disease may occur at all 
( periods of life and in both sexes, but its aggravated forms are peculiar 
to middle life and advanced years. It is always secondary to some 
disturbance of the nervous system. It is frequently the symptom of one 
of several internal disorders, such as malarial affections, tuberculosis, 
carcinoma of the viscera, disorders of the liver or kidneys (especially 
jaundice, B right's disease, and diabetes), and disturbances of the ali- 
mentary canal, including those due to intestinal worms, hemorrhoids, 
and dietetic or medicinal ingesta. It is common in the gouty, the 
rheumatic, and the neurotic, and undoubtedly is due often to auto- 
intoxication. It is often reflex in character, and may be associated with 
almost every one of the functional, and not a few of the organic, dis- 
orders of the uterus and ovaries. The same may be said of its depend- 
ence upon the genito-urinary diseases of the male sex, including stone 
in the bladder, stricture of the urethra, disorders of the testes and epi- 
didymis, and perverted sexual hygiene. Through the reflex sympathy 
of one part of the skin with other regions it is not at all unusual for 
one point of pruritus to be the exciting cause of new foci of the dis- 
order, even at some distance from the original seat of itching. A 
predisposing cause may often be found in hyperesthesia, either inherited 
(or acquired (sometimes as a result of long-continued inflammatory der- 
matoses, such as eczema), as a consequence of which insignificant exter- 
nal irritants cause pruritus. Bronson thinks a diminished tactile sense, 
which implies an imperfect conduction of sensory impressions, is often 
ja. predisposing cause. 

Lastly, moral emotions of a depressing character play an important 
|part in the etiology of pruritus. Mental distress occasioned by bereave- 
ment, separation from relatives, misfortune of all sorts, and anxieties 
rs to the future, often find physical expression in the disease. 
Pathology. — The disease is essentially a functional disorder of the 
nerves of sensation supplied to the skin, and of itself is incapable of 



720 SEXSORY DERMATO-NEUROSES. 

producing objective symptoms. This fact can, in some cases, be clin- 
ically demonstrated, as the seat of the pruritus, even though exhibit- 
ing artificially produced lesions, will, when protected from external 
injury, speedily regain its normal appearance, the pruritus no less con- 
tinuing. It is probable, though not certain, that the nerves also in 
this disease undergo no structural change, but merely convey to the 
periphery a perverted sensation that is often reflected from some cen- 
tric point of disturbance. 

Diagnosis. — The recognition of general pruritus is usually not diffi- 
cult, though the secondary results of the disease are apt to be less 
characteristic than its early phenomena. The complaint of the patient, 
the absence of cutaneous disease sufficient to explain the symptoms, 
and especially the discovery of an efficient cause in some visceral or 
systemic disorder, are all significant. 

One of the most constant features of general pruritus is visible only 
when the clothing of the patient is entirely removed. It then becomes 
evident to the eye that the affected regions are, in the order of fre- 
quency, those most accessible to the hands. The posterior are much 
less involved than the anterior body-surfaces. The small of the back 
and interscapular regions are usually untouched. The tibial regions 
of the legs and the forearms suffer more than the calves and the upper 
arms. The lower belly and inner faces of the thighs are punished 
more severely than the breast and outer faces of the thighs and the 
hips. The clavicular regions are more excoriated than the back of the 
neck. There is no more diagnostic sign of pruritus than this, and it 
is one too often ignored by the practitioner, who prescribes under these 
circumstances for a " disease of the blood." 

It must be admitted, however, that when the disease is localized 
and complicated, as it frequently is, by an eczema or a dermatitis, 
doubt may arise. Attention should then be paid to the history of the 
disorder, which may reveal the fact that the pruritus preceded for some 
time the cutaneous symptoms, and may disclose even more. Intelli- 
gent patients will often assure the physician of the real nature of the 
malady, by voluntarily remarking that the skin-symptoms disappear 
upon the region that is not scratched, though the pruritus continues. 
In all cases the influence of externally operating agencies should care- 
fully be eliminated. 

Prurigo, with its infiltrated skin, its primary papules, and its severe 
itching, beginning in early infancy and commonly persisting through 
life, can scarcely be confounded with pruritus cutaneus. 

Treatment. — The degree of success to be obtained in the treatment 
of pruritus cutaneus is largely proportioned to the skill with which the 
cause of the disease is recognized and remedied. Taking into consid- 
eration the number of systemic and visceral disorders which may in 
different cases be responsible for the skin-symptoms, it is clear that an 
exhaustive study of the mental and physical history of each patient 
will be essential at the outset of treatment. The cause once recognized, 
the treatment should be directed to the special disorder discovered ; and 
this largely requires the skill of the general practitioner. The gastro- 
intestinal tract, the kidneys, the liver, the bladder, the uterus, the 



PARESTHESIA. 721 

I- prostate gland, the rectum, and indeed any one of the viscera, may 
L require therapeutic management. All internal causes of cutaneous 
\ irritation should as far as possible be removed, and to this end atten- 
- tion should particularly be directed to any medication to which the 
patient may have been subjected, and which may have aggravated the 
L complaint, and also to the diet, which should be regulated in accord- 
L ance with the principles given under Urticaria (page 194) and Eczema 
(page 346). 

In atonic conditions strychnine, iron, and other tonics are indicated. 
, The nutrition of the nerves and of the skin can often be improved by 
, the judicious use of cod-liver oil and other fats. 

The attempt to relieve pruritus by the internal use of sedatives is 

1 not to be commended except in extreme cases. The narcotics, while 

they may give temporary relief, tend to relax the skin and in the end 

to aggravate the disorder. This is especially true of the preparations of 

■« opium. The bromides, antipyrin, phenacetin, sulfonal, or even chloral 

\ may be given for brief periods in extreme cases, but always with the 

[\ understanding that any one of these remedies, after temporary relief, 

I may aggravate the condition for which it was given. Furthermore, 

I there are strong reasons for refusing to employ in pruritic disorders 

j preparations containing opium, cocaine, cannabis indica, conium, and 

j other drugs intended to relieve the subjective sensations by internal 

medication. Many well-nigh incurable cases of the " cocaine-habit " 

j, have been begotten by treatment of this sort when the patient, often a 

t nervous woman with an intolerable pruritus vulvae, is in a condition 

I peculiarly susceptible to the action of remedies of this class. The 

latter should always be regarded as the last resort of the practitioner, 

I and a confession of weakness in not discovering the special cause 

effective in the case with which he is for the time confronted. 

Cathartics and laxatives and an abundant supply of pure water 
internally employed as directed for relief of acute eczema (pp. 335, 336), 
as well as diaphoretics and diuretics, are often of value in eliminating 
toxins to which pruritus may be due ; in depleting the cutaneous ves- 
sels ; and possibly in a reflex way by diverting irritation to other 
regions. Jaborandi and pilocarpine have thus been employed to ad- 
vantage. In children full doses of quinine sometimes relieve pruritus, 
while in adults large doses of calcium chloride occasionally will accom- 
plish the same result. Cannabis Indica and gelsemium at times are 
effective, but should be prescribed with great caution. 

The indications for local treatment are to protect the skin from all 
sources of irritation and to relieve the itching. Hyperesthesia of the 
skin is common in pruritus, either as a predisposing cause or as a result 
of long-continued pruritus. In consequence very slight external irri- 
tation may suffice greatly to aggravate the itching, and every precaution 
should be taken to protect the skin from exposure of all kinds. First 
in importance is the clothing. The garments worn next the skin should 
be of cotton, lisle-thread, linen, or silk, never of wool, and the meshes 
should be filled with an impalpable powder to reduce to a minimum 
the friction of the garments on the skin. All other clothing should 
be as light as possible and yet be warm enough for protection. If the 

46 



722 SENSORY DERMA TO-NEUROSES. 

patient live in a climate where sudden changes in temperature are com- 
mon, the clothing should be regulated accordingly. The object is to 
keep the skin at an even temperature and to protect it from sudden 
changes. In cases in which the pruritus is due largely to the hyper- 
esthesia the itching may be entirely relieved by dusting the surface 
with a simple powder and completely covering it with a layer of cotton- 
wool or other protective dressing. 

Hot baths, unless specially indicated, and the too free use of soap 
may render the skin unduly sensitive. The bran, oatmeal, alkaline, 
and other demulcent baths recommended in the chapter on General 
Therapeutics are those most generally useful. After the bath the 
surface should be patted (not rubbed) dry and covered with a dusting- 
powder or other selected application. When the skin is free from ex- 
coriations and other lesions the cold douche, alternate hot and cold 
douching or sponging, or even the cold salt-water sponge may be used 
to improve the tone and vigor of the skin. For localized pruritus hot 
baths of four or five minutes' duration, followed by drying and the 
immediate application of a protective dressing, are often grateful and 
beneficial. The water should be as hot as can be tolerated, and to it 
may be added borax or sodium bicarbonate. 

Scratching is a common source of irritation and one that is difficult 
to set aside. Until this is accomplished, however, relief cannot be ob- 
tained, as whenever the skin is scratched or rubbed there is produced 
a local hyperemia, or even a dermatitis, which adds to the cutaneous 
irritation, not only at the site of the rubbing, but also by reflex action 
in other regions of the body. It is not sufficient to tell the patient not 
to scratch ; the surface must be protected by proper dressings, and the 
itching relieved by the use of antipruritics. Bronson suggests that 
patients be allowed to obtain relief at times by firmly pressing upon 
the surface or by gently drawing over it an oiled or a wet cloth. 

The substances which have been employed topically for the relief of 
pruritus cutaneus are almost without number, a fact warranting the 
conclusion, corroborated with every wide clinical experience, that each 
occasionally fails to afford the desired relief. That preparation, more- 
over, which is at one time of the highest value, at another period in 
the history of the same case will disappoint. Attempts to secure relief 
by such topical applications should, however, always be made, and will 
often be followed by gratifying results. 

The sedative and antipruritic lotions, liniments, and dusting-powders 
described on pages 342-345, together with their methods of prepara- 
tion and application, are valuable and sufficient in most cases. They 
may be further modified by the addition of substances recommended in 
the following paragraphs. The dusting-powders are of special value 
in furnishing mechanical protection. When a decided antipruritic 
effect is desired the Anderson, or a similar, powder may be used. In 
some localized forms of pruritus more complete protection with oint- 
ments, pastes, or even the glycogelatins, may be secured. 

Of all antipruritics, carbolic acid easily takes first place. In most 
of the lotions recommended above it is used in strength of 1 to 5 per 
cent. In oils or liniments it may be used much stronger. Bronson 



PARESTHESIA. 723 

uses it even to 25 per cent., stating that it is much more slowly ab- 
sorbed than in aqueous solutions, and therefore less likely to produce 
systemic effects. A favorite formula with him is the following : 



R 



Acid, carbolic, 


oj-y ; 


4-8 


Liq. potass., 


33; 


4 


01. lini, 


3j; 


30 



M. 



It is to be shaken before using, and may be scented with bergamot. 
These stronger preparations of carbolic acid, even in the oils, should 
be used over only small areas, for fear of toxic effects. 

Other remedies that may be used in lotion, oil, liniment, ointment, 
or paste, in strengths varying from 1 to 5 per cent, or more are : 
salicylic acid, hydrocyanic acid, menthol, camphor, thymol, salol, creo- 
sote, chloral, and chloroform. Two or more of these remedies may be 
combined in the same lotion. Morphine, atropine, and cocaine may be 
added to lotions with occasional advantage. 

Ointments and pastes are irritating to many pruritic skins, but at 
times are more acceptable than the lotions and oils. 

Chloral-camphor, a pungent, syrupy liquid obtained by triturating 
an equal amount of the two substances in fine powder, is an anti- 
pruritic remedy of value in certain cases if applied in a salve contain- 
ing 1 drachm (4.) to the ounce (30.) of salve, and is comparable in its 
action to phenol-camphor, described in the chapter on General Thera- 
peutics. Among other remedies occasionally of service are ichthyol, 
resorcin, and mercuric chloride. Bronson speaks highly of hydrogen 
peroxide. The preparations of tar are not well tolerated as a rule, but 
in some instances are exceedingly valuable. The liquid preparations 
(page 352) are to be preferred. In atonic cases, with diminution of 
the tactile sense, the use of electricity over the spine has been followed 
by good results. 

In Senile Pruritus the progressive atrophy and degeneration of 
tissues may be checked or retarded by management proper to each 
case. Locally, electricity or hot and cold douches may aid in stimu- 
lating the skin to renewed vigor. 

Treatment of the regional forms of pruritus is that above de- 
scribed, with such modifications in the dressings as may be necessitated 
by the special location. 

In anogenital pruritus the hot bath described above at night is 
especially to be recommended. Exception should be made here to the 
rule with regard to the exclusion of tars generally from the treatment 
of pruritus, as in the distressing itching of the scrotum and the anus 
they are often essential. The tincture of tar, oil of cade, and oil of 
white birch will here often be needed. Fissures and areas of infiltra- 
tion may be painted with compound tincture of benzoin or solutions of 
silver nitrate containing gr. x to 3j (0.66—4.) to the ounce. The scrotum 
when attacked usually requires the use of a suspender, or suspensory bag, 
lined with soft lint or with borated cotton, which may be covered with 
a dusting-powder, wetted with a lotion, or smeared with an unguent. 

For pruritus of the vulva Wiltshire ! recommends decoctions of 

1 Brit. Med. Jour., March 5, 1881, p. 328. 



724 SENSORY DERMATO-NEUROSES. 

almond-meal, marshmallow, slippery-elm, and rice ; and in case of 
failure of the latter, an infusion of tobacco 2 ounces (60.) to the pint 
(480.). Vaginal injections of hot water, and tampons or cocoa-butter 
suppositories medicated with opium, belladonna, or carbolic acid, are also 
available. Mercuric chloride lotions [gr. J— j to 3j (0.016-0.06 to 30.)] 
are recommended by many writers. 

Iodoform, oleate and muriate of cocaine, the latter in from 2 to 4 
per cent, solutions ; 1 ounce (30.) of the fluid extract of coca, to 2 or 
4 (64.-128.) of water ; and linseed oil (especially for pruritus ani), are 
also recommended. 

Jullien recommends in pruritus of the vulva : 



R 



Sig. 



Zinc, oxid., 


3vj ; 


24 


Acid, salicylic, 


gr. xv ; 


1 


Glycerin., 


3vj; 


24 


Apply as required. 







M. 



Cheron, in pruritus of the vulva attending the menopause, 
successfully used : 



R Veratriae, gr. iij ; 

Axung., lj; ' 30 



20 
M. 



He also administers in pill-form y^ grain of veratria rubbed up 
with licorice. 



Squibb's formula is : 

R Acid, tannic, 9j ; 1 

Spts^vin/rectif.,} ™&*> ** 15 

Aq. dest.. ad f ^iv ; ad 120 

Sig. Apply morning and evening on a rag. 



33 
M. 






Lastly, it should not be forgotten that many cases of intractable 
pruritus are best managed when the attention of the patient is diverted 
from the malady by the distraction incident to travel, aided by change 
of scene and climate. 

Prognosis. — Pruritus senilis is usually an intractable disorder, and 
when dependent upon senile alteration of the cutaneous tissues is in- 
curable. For all other forms of the disease a prognosis should be 
formulated with reserve. Under the influence of systematic and ap- 
propriate treatment the happiest results are often obtained. Other 
cases, especially those associated with hypochondriasis, may bid defi- 
ance to all medicinal measures. Relapse of the local forms of the 
malady, especially of that of the anogenital region, is common. In 
many of these patients the treatment serves merely to palliate the 
disorder, which recurs with every renewal of the cause. 

Pruritus Hiemalis (Prurigo Hyemalis, " Frost Itch," 
Winter Prurigo). — Under the first title Duhring 1 described a harsh 

1 Phila. Med. Times, January 10, 1874. See also a later but independent observa- 
tion by Hutchinson : Lectures on Clinical Surgery, 1878, vol. i., pt. 1, p. 100; and Brit. 
Med, Jour., 1875, ii., p. 773. 



PARESTHESIA. 725 

and pruritic condition of the skin, essentially unattended by structural 
alteration, invading all surfaces of the body, but chiefly the inner 
faces of the thighs, the calves of the legs, and the neighborhood of the 
joints of the lower extremities, usually occurring in the autumn and 
continuing until the following spring. It possesses many features in 
common with the forms of pruritus already described, including varia- 
bility in the subjective sensations awakened, nocturnal exacerbation, 
and the absence of primary eruption. The secondary results are also 
similar, being sequels of self-inflicted injury in the form of roughness, 
perifollicular redness and papulation, torn and fractured hairs, excori- 
ations, blood-crusts, and, in severe cases, an induced dermatitis. It, 
however, abates in severity with a rise of atmospheric temperature, 
though there is occasionally noted persistence of the distress after such 
weather-changes. The affection, moreover, is one which occurs in 
persons otherwise enjoying perfect health, in those of every social 
grade, irrespective of the [character of the clothing worn and of the 
habitual use or the neglect of the bath. It is, without question, a dis- 
ease of northern climates, more particularly of those where the varia- 
tions of temperature between the extremes of the summer and of the 
winter range between — 30° F. and 100°. The description by Duh- 
ring presents a picture (with an accuracy verified by clinical observa- 
tion) which justifies the recognition of the disease as a form of cutaneous 
pruritus. Its treatment is that detailed above, the author named lay- 
ing stress upon emollient unguents, glycerin in the form of lotion or 
ointment, and alkaline baths. The dusting-powders, when employed 
after the tepid bath, have proved more serviceable than any fat-con- 
taining substance. 

Prairie Itch. — This is a popular term applied largely in the 
Western, Northwestern, and Southern States of America to a cutaneous 
affection productive of itching sensations. It is supposed to be the dis- 
order popularly described also as the " Texas Mange," " Ohio 
Scratches," " Swamp Itch," " Lumberman's Itch," etc. A para- 
sitic origin has been claimed for it by several observers who also 
insist upon its contagious character and its curability by parasiticides. 

Personal experience has led to the conviction that these terms are 
loosely applied to a group of cutaneous symptoms of diverse origin. 
The most frequent by far is a pruritus, of the kind described above as 
pruritus hiemalis, occurring in the autumn, winter, or spring of the 
year, and aggravated by the coarse and cheaply dyed woollen under- 
garments of the poor and hard-working inhabitants of lumber-camps, 
mining-districts, etc. With these causes in full operation, there is often 
aggravation after swallowing drugs for relief of the pruritus, based upon 
the idea of " purifying the blood." 

With these pruritic cases occur those of undoubted scabies, for the 
study of which the reader is referred to the chapter devoted to that 
subject. The proportion between the purely pruritic and parasitic 
cases of this class cannot definitely be determined. It probably varies 
in different places and seasons, the proportion of cases of scabies 
increasing in the lumber-camps when they are reinforced by newly 



726 THYROID CACHEXIA. 

arrived immigrants infested with acari. It decreases to probably not 
more than from 1 to 2 per cent, of all skin-diseases in the interior vil- 
lages and towns of the West and Northwest where there has been no 
immigration for some length of time, and where, after the first onset of 
sharply cold weather in the autumn, a large part of the inhabitants 
suffer from pruritic sensations in various degrees. 

A review of the somewhat scanty literature of this subject 1 suggests 
the conclusion that the disorder popularly designated as " prairie itch," 
etc., is far more rare in Europe than in America. It is possible that 
the situation of those parts of the United States where this group of 
skin-affections seems to prevail (at a great distance from proximity to 
the seashore, and still further separated from the Gulf-stream) may play 
an important part in the extraordinary sensitiveness of the skin to 
climatic changes. Certain it is that a great number of these affections 
are entirely relieved by removal to a suitable climate, more particularly 
to one of the Eastern, Southern, or extreme Western States. 

Treatment. — The therapy of this affection is that of pruritus, 
already described, save where a parasite is recognized as the efficient 
cause, as in cases of scabies. 

The Prognosis is favorable, though the disease is at times intracta- 
ble, persisting or recurring with repeated thermometric variations until 
the warm season is at hand. 

MYXEDEMA. 

(Gr. fJ-v^a } humor ; olSe u } to swell. ) 

(Cretinoid (Edema, Cachexia Strumipriva, Cachexia Thy- 
roidea. Fr. y Cachexie pachydermique.) 

This disorder was first described by Sir William Gull, 2 in 1873 ; 
and it has since been studied, both abroad and in this country, by many 
observers. 

A complete description of the disease and a resume of literature are 
found in the report of the Clinical Society of London for 1888, and in 
Murray's elaborate contribution to the same subject, in the Twentieth, 
Century Practice of Medicine, vol. iv., 1895. The report embodies the 
results of the researches of a committee — including Ord, Horsley, and 
others — specially appointed by the Society to investigate the subject. 

Symptoms. — The disease occurs in both acute and chronic manifes- 
tations, usually after the fortieth year, and in women more often than 
in men. It may, however, first be noticed in childhood. 

At the outset there is observed a gradually occurring persistent and 
remediless anaemia, succeeded in turn by mental hebetude, sluggish- 
ness of body-movements, and a characteristic change in the integument. 

1 See two papers by one of us, entitled "On the Affections of the Skin Induced by 
Temperature-variations in Cold Weather," Chicago Med. Jour, and Examiner, March, 

1885, and February, 1886. Obersteiner: Wien. med. Woch., 1884, No. 16. Brodie: 
Peninsular Jour, of Med., 1853-54, vol. i., p. 506. Jones: Kansas City Med. Index, 

1886, with views of several Western physicians. Clark : Med. Age, 1886. Payne : 
Brit. Med. Jour., May 3, 1887. 

2 Trans. Clin. Soc. London, 1874, vii., p. 170. 



MYXCEDEMA. 727 

The skiu becomes dry, rough, yellowish, waxy, translucent, and firm, and 
refuses to pit on moderate pressure. The surface involved is commonly 
the seat of a fine furfuraceous desquamation, the mucous membranes 
often participating in the morbid process. In the cheeks there is 
usually perceptible a brawny redness ; defined at times as a sharply 
circumscribed, pinkish flush, due to distention of the minute capillaries, 
extending quite to the lower eyelids, which may, as in Ball's cases, be 
wrinkled, boggy, and swollen. The eyes, for this reason, seem smaller 
than natural and more widely separated. In consequence of the swelling 
and immobility of the features the facies is characteristic : the broad, 
thick nose ; swollen, pendulous, or even everted lips ; expressionless 
eyes ; and leathery cheeks, producing upon the observer the impression 
of a mask. The skin of the other regions of the body participates in 
these changes, the backs of the hands, for example, becoming wrinkled 
or distended, the palms dry and fissured, the feet participating in the 
same morbid process, the hair falling in nearly 90 per cent, of cases 
even to the production of extreme baldness, the nails becoming discol- 
ored, grooved, and cracked, and the teeth often carious, fragile, or 
wholly lost. The mucous membrane of the mouth (gums, palate, 
pharynx) becomes tumid and fungous. 

In the triangles at the side of the neck, and also at its back, are 
" bolsters " of fat. The hair of the head becomes harsh and scanty ; 
alopecia may be complete. Pigment-alterations readily occur; moles 
increase in size ; and the general tint of the skin may vary from that 
of dry parchment to the hue of Addison's disease. The gait is waddling 
and uncertain. The thyroid gland atrophies. Anaesthesia is of common 
occurrence. The tongue, uvula, and fauces are often so thickened and 
immobile as to make speech slow and indistinct. The temperature is 
usually subnormal, the mental faculties seriously impaired, the sight 
and hearing altered, digestion vitiated, and the muscular strength 
greatly reduced. 

The course of the disease is chronic, lasting for years, and termin- 
ating usually in a state of marasmus with fatal issue. 

Etiology.— The cause of myxoedema is imperfectly understood, 
though its association with abolition of the thyroid gland (after patho- 
logical change or ablation) is generally admitted. Stokes reports ten 
cases of acute myxoedema following thyroidectomy. In these cases, 
beside the rapid occurrence of the symptoms enumerated above, there 
were convulsive seizures of an epileptiform character. Of four hundred 
and eight complete thyroidectomies analyzed in the Clinical Society's 
report, in sixty-nine myxoedema developed. The result did not occur 
when a part of the gland was left. The influence of heredity is distinctly 
shown in cases reported by Ball, Ord, Saville, and Taylor. The disease 
affects women more often than men, in the proportion of seven to one. 
Children are attacked, but the malady is more common in individuals 
between thirty-five and fifty years of age. 

It is undetermined what relations, etiological or other, subsist between 
the members of an interesting group of maladies, all characterized by 
cutaneous changes or dystrophy of the appendages of the skin, and total 
or partial abolition of the functions of the thyroid gland. In this group 



728 THYROID CACHEXIA. 

are to be named not merely myxoedema, but also myxedematous cretin- 
ism, acromegaly, and Graves's disease. These maladies are denomi- 
nated by some authors the " thyroid cachexias." 

Pathology. — In nearly all cases examined the thyroid gland is 
found to be markedly reduced in size and its glandular structure 
seriously impaired by substitution of fibrous connective tissue for the 
epithelial cells lining its secreting acini. At first there is a small 
round-cell proliferation, which gives place to changes resulting even- 
tually in a firm thickening of both the gland and its capsule. The 
lumen of the arteries becomes obstructed ; and, in cases, new-formed 
lymphatic tissue is found surrounding the atrophied lobules. 

Examination of affected regions of the skin discloses slight epider- 
mal atrophy, replacement of connective-tissue trabecule with fine 
nucleated fibrillar, a small-cell infiltration in the upper part of the 
corium, and an endarteritis obliterans similar to that recognized in the 
thyroid gland. The epithelium of the coil- and sebaceous glands is the 
seat of swelling and proliferation, which eventually produces occlusion 
of the lumen of these emunctories and explains largely the cutaneous 
symptoms of the malady. The hair-follicles and the nerves (fibrosis 
of hair-pouch, perineuritis) may or may not be invaded by a similar 
process. 

Diagnosis. — Cases of myxoedema are readily distinguished from 
those of elephantiasis by the generalization of the symptoms, the nervous 
state of the patient, the fat-deposits, and the condition of the thyroid 
gland. Acromegaly involves the bones ; in lepra there are commonly 
anaesthetic symptoms or characteristic tubercles. 

The Treatment of myxoedema has hitherto aimed at amelioration of 
the symptoms by the employment of roborant and tonic measures ; alka- 
line and sulphur baths ; electricity and massage. The later method of 
treatment, however, is by thyroid-grafting, by administration of thyroids, 
and by hypodermatic injection of from 5 to 15 minims of liquid extract. 1 
Whether there be employed the gland itself of the sheep, the liquid 
extract, or the powder skilfully prepared by evaporation, or Vermeh- 
ren's extract precipitated by alcohol, the results are satisfactory in so 
large a proportion of cases that the prognosis of this group of disorders 
presents no longer an element of gravity. The headache, faintness, 
loss of weight, neuralgias, and even albuminuria, with other symptoms 
immediately following the employment of the thyroids named above, 
do not seem to have an adverse influence upon the remoter benefits 
received from the treatment. 

1 Cf. " Feeding Thyroids in Myxoedema," by J. J. Putnam ; Amer. Jour. Med. Sci., 
August, 1893. 






CLASS VIII. 
PARASITIC AFFECTIONS. 



The disorders due to invasion of the skin by parasites possess many 
features in common with those already described. In them, as in others, 
are observed the hyperaemic and exudative processes which result in 
surface-lesions of similar type and career. They differ, however, from 
other affections of the integument in that they are all induced by para- 
sites of either vegetable or animal origin ; and are, as a consequence, 
commonly characterized by certain special features. They involve the 
skin and its appendages, their symptoms being at times displayed 
chiefly in the integument proper, and at other times in one or more of 
the cutaneous appendages, according to the mode of propagation and 
attack, peculiar in each case to the parasite present. They are all in 
different degrees contagious ; and, being induced by local and tangible 
causes, are usually relieved by external treatment. Their importance 
in cutaneous medicine rests not only upon the facts named above, but 
also upon the too general misconception regarding their nature, since 
there are many patients treated by internal remedies ingested vainly 
for long periods of time, who suffer from parasitic disorders often 
remediable by very simple local measures. 

It should not be forgotten, however, that, distinct though these mal- 
adies be in an etiological sense, they are yet often practically com- 
mingled with others. Thus, an eczematous scalp in a child may by 
accident become the habitat of lice ; and the eczema induced originally 
by the acarus scabiei may persist long after destruction of the parasite. 

The term tinea, derived from a Latin word meaning " a moth or 
worm," has by common consent been adopted as a generic designation 
of the cutaneous disorders induced by the presence of vegetable organisms. 

DISORDERS DUE TO VEGETABLE PARASITES. 

TINEA FAVOSA. 

(Lat. favus, a honeycomb.) 

(Honeycomb Ringworm, Porrigo Favosa, Favus. Fr., Teigne 

Faveuse; Ger., Erbgrind.) 

Symptoms. — Favus aifects chiefly the scalp, but it also occurs upon 
the glabrous portions of the skin and upon the nails. In the former 
situation it is usually first recognized by the development of minute, 
subepidermic, yellowish or reddish puncta, visible through the trans- 
lucent stratum corneum at the site of implantation of the hairs. A 

729 



730 PARASITIC AFFECTIONS. 

circle of delicate vesicles may surround these spots. Puncture with 
a needle usually gives exit to puriform matter. In the course of a 
fortnight or more these lesions cover themselves with pin-head to 
pea-sized and somewhat larger, friable, circular, and elevated crusts, 
having the yellowish tinge of the lemon or of sulphur, and a concavo- 
convex shape, with the free concave face of the disk exposed. At 
the centre of the umbilication thus presented to the eye one or several 
hairs usually make exit to the surface. The inferior surface of this 
disk, or scutulum, rests upon the scalp, which is either moist and 
deprived over a circumscribed area of its epidermis, or is smooth, dry, 
reddened, and tender. When the crust is removed by traction upon 
the hairs or otherwise a minute cup-shaped depression is left at the 
point where the lowest level of the favus crust was in intimate con- 
nection with the epidermis. 

The subsequent features of the crusts, the hairs, and the scalp are 
subject to variation. The crusts may acquire a brownish or a greenish 
tinge by admixture with dirt or with dried pus ; may coalesce (favus 
squamosus); or may, by gradual desiccation, exchange the yellowish 
hue for the dirty-whitish shade of old mortar, a substance which they 
then resemble in dryness and friability. The hairs invaded both in 
the sheath and shaft may lose their lustre ; become fragile ; appear as 
fractured relics of longer filaments ; readily be extracted from their 
follicles ; and finally be shed, leaving hair-sacs destined to atrophy and 
incapable of reproducing a pilary growth. The scalp may first be the 
seat of an extensive hyperemia or exudation going on to the forma- 
tion of pus, when the fungus is a source of acute irritation in conse- 
quence of its active development. Later, when its destructive work 
may be said to have been accomplished, the scalp-surface is bald, irreg- 
ularly atrophied, or disfigured with cicatrices, which at first are of a 
deep-red color, but which gradually fade, while here and there remain 
tufts of hair that have survived the attack. 

The lesions may be discrete or be confluent, and may vary in either 
case. Occasionally but a few small and ill-developed crusts form upon 
the surface. The entire scalp is not often covered with a confluent 
favus-crust. The disease is usually chronic in its course. Untreated, 
it may undergo spontaneous involution after total destruction of all 
hairs and production of general follicular atrophy, but this is rare. 
It may last for fifteen or twenty years, and even longer. It is often 
accompanied by adenopathy. 

The disease usually awakens a noteworthy degree of itching, and, 
as a result, it is not rare to find the favus-crusts torn and broken by 
the comb or the nails. 

The yellowish disks of the disease occur also in typical development, 
though more rarely, upon the surface of the face (including the bearded 
cheeks, lips, and chin), and upon the trunks and extremities. Fox, of 
New York, has photographed a patient's knee which was covered on its 
extensor aspect with favus-crusts. 

When the nails are invaded, light or deep-yellowish, circumscribed 
spots become visible through the nail structure, and by extension of 
these, in consequence of the growth of the parasite, the nail-tissue 



TINEA FAVOSA. 731 

may be thickened, irregularly split, laminated, separated from its 
matrix, or atrophied. The complication is rare, and is supposed to be 
due to transfer of the parasite from the scalp to the hands in the act of 
scratching. When it exists the epidermis fringing the nail is usually 
also involved. 

Upon the so-called " non-hairy " portions of the body favus occurs 
in the same forms as elsewhere, the localities in the order of frequency 
being those most exposed to the hands charged with the parasite, or to 
other sources of the disease, viz., the hands (chiefly the backs and nails), 
the upper and lower extremities, and the shoulders. It is a striking 
fact that favus may exist for years on the scalp without spreading. At 
a single clinic we have exhibited five patients affected with favus, all 
scalp-cases, the eldest, a male, twenty-five years of age, who had suffered 
from the disease for twenty years without occurrence of the lesions 
elsewhere. 

In favus of the body-surface, outside the scalp, there is often a re- 
semblance to ringworm in the production of circular patches with an 
active border made up of vesicles or of papules, which may have a 
favus scutulum as a centre ; or several of these cups may irregularly 
be spread over circles of scaling patches. In these cases there is often 
an acuity of symptoms not observed in scalp-cases and coincident 
gastrointestinal signs of irritation, vomiting, etc., which Kundrat be- 
lieves may originate in favus of the mucous surfaces of the oesophagus 
and gastro-intestinal tract. 

The odor of fully developed favus is so characteristic that by it 
alone a diagnosis has been established. It is usually compared to the 
odor of mice ; also to that of the urine of cats. It should not be 
confounded with the peculiarly disgusting odor of neglected scalps 
affected with lice or covered with pustules and filth. The disease not 
infrequently coexists with other cutaneous, parasitic, and non-parasitic 
diseases, as, for example, seborrhoea, eczema, and tinea tonsurans. 

Favus of the Nail (Fa vie Onychomycosis). — Rarely one or 
several of the nails may be the seat of the fungus, and either the entire 
body of the nail or but a part of it. The lesions are maize-yellow 
points or macules where the substance of the organs is eroded, fissured, 
or split into striations — changes quite like those induced by other causes. 
The connections of the nail with the underlying nail-bed and nail-folds 
are loosened, wholly or in part, while the matrix still holds the nail 
firmly in position. 

Etiology. — Favus is always produced by the presence and develop- 
ment of the vegetable organism which is named after its discoverer, the 
achorion Schonleinii (Fig. 88). The disease is contagious simply because 
the parasite which produces it is capable of transmission from man to 
man, as also from animals to man, and vice versa. It is often conveyed 
to man from mice, cats, dogs, rabbits, fowls, and ponies ; but when 
derived from the lower animals is most often transmitted from mice to 
cats and from cats to man. It shares with other diseases originating 
from vegetable parasites the peculiarity of attacking certain individuals 



732 



PARASITIC AFFECTIONS. 



specially predisposed to such invasion, either by reason of physical 
peculiarities of organization or because of accidental and fortuitous cir- 
cumstances. It is most common from infancy to the thirtieth year of 
life. It is less common in the United States, Austria, and England 
than in France, Scotland, and Poland. It is said by Bergeron 1 to be a 
disease of the country, while tinea trichophytina prevails in the cities. 
This statement is corroborated by general experience. Favus is more 
common in public than in private practice, and the larger number of 
clinical patients with favus come to the city from the country. 




Achorion Schonleinii : a, spores ; b, c, sporophores. (After Cornil and Ranvier.) 

Evidences of contagion are exhibited in those cases in which several 
members of the same household are affected with the disease ; but in 
other cases the absence of a history of contagion after exposure indi- 
cates the relative difficulty experienced in propagating the contagious 
element in the case of favus. Thus, one individual exposed among 
a dozen who are diseased will fail to exhibit favus-crusts ; and the 
latter by no means form in all situations of the same body where the 
fungus can be discovered by the microscope. Aubert, 2 indeed, presents 
an argument in favor of the production of the disease by traumatism, 
the resulting wounds, excoriations, etc., becoming by accident the seat 
of the disease. It is not very rarely discovered under poultices and 
fomentations. 

Occasionally favus occurs in special localities with such development 
among men and the inferior animals as to constitute an epidemic. 
Girard 3 reports thus the simultaneous existence of the disease among 
sixteen cows and four children in the village of Nantoin, in France. 
It is propagated also upon the skin of rats and mice, from which it is 
transmitted to man, often through the medium of the domesticated cat 
and dog. 

Pathology. — Under the microscope the fungus is readily recognized 
in the root-sheaths, the bulbs, and the shafts of the hairy filaments near 

1 Etude sur la Geographie et la Prophylaxie des Teignes. Paris, 1865. 

2 "R61e de Traumatism dans l'Etiologie de la Teigne faveuse," Annal. de Derm, et 
de Syph., April, 1881. 

3 Lyon med., August 18, 1880, p. 547. 



TINEA FAVOSA. 733 

the scalp. At a distance of about two inches from the bulb the para- 
site ceases to appear in the tissue of the hair. It is also seen upon the 
free surface of the skin. The favus-crust, softened by the addition of 
a little water or solution of potassium hydroxide, may be placed upon 
the slide of the microscope without other preparation for its study. The 
hairs may be examined in the same manner or they may be stained by 
the methods given for staining the ringworm fungi. Under a good 
one-fourth- or one-sixth-inch objective the vegetation is seen to be 
composed of intricate masses of mycelium and spores in great 
quantity. 

Quincke 1 attempted to distinguish between three varieties of the 
favus fungus, designated respectively as a, ft, and y. Elsenberg, Krai, 
Pick, Unna, and others have, however, arrived at different conclusions 
upon the same subject, some recognizing but two of Quincke's forms ; 
others, two separate forms not corresponding with the a, /?, or y form 
of Quincke ; and still others, corresponding with none of those pre- 
viously described. The majority of observers agree that there is but 
one achorion fungus, displaying itself in several forms both under the 
microscope and clinically, all differences being due to accidental influ- 
ences (varying amount of heat, moisture, and friction in the involved 
surface). 

The threads of the fungus usually preponderate, and appear as nar- 
row, flattened, ramifying, short or elongated, linear cells or tubes, 
which may be simple and empty, or be divided more or less regularly 
by transverse partition-walls, transforming the longer and simple into 
shorter and compound cells. The latter often contain in their cavities 
sporules clinging to either side, in which case the mycelial threads are 
termed spwophores. These sporules are the vegetative part of the 
cryptogamous fungus, and develop by multiple subdivision into cells, 
which may also themselves similarly increase in number, or by the 
production, at the terminal extremities of certain mycelial threads, 
of spores or conidia. The conidia are encapsulated or are strung 
like beads upon a necklace, and they appear as round, oval-shaped, 
angular, or very irregularly contoured bodies, often provided with 
partition-walls like mycelium, constituting thus compound cells. At 
the same time an amorphous granular matter can usually be distin- 
guished in the mass of the fungus. The hyphse vary in width from 
0.0023 to 0.0030 mm.; and the spores from 0.0023 to 6.0052 mm. 

Examination of the invaded scalp reveals, according to Unna, 2 the 
presence of the fungus at the lower border of the upper three-fourths 
of the root-sheaths, where chains of conidia appear among the histo- 
logical elements. His view is that the cuticle of the hair offers a rela- 
tive resistance to the growth of the vegetation ; that the latter first 
penetrates the stratum corneum and the follicular orifice, and then 
stretches, upon the one hand, into the cortex and medulla through the 
cuticle of the hair ; and, on the other hand, passes to the inner root- 
sheaths, the outer remaining always intact. In the epidermis the 
fungus is found chiefly between the superficial and deep portions of the 

1 Monatshft. f. prakt. Derm., 1889, Bd. viii.. S. 49. 

2 Vierteljahr. f. Derm. u. Syph., Bd. vii., S. 170. 



734 PARASITIC AFFECTIONS. 

stratum corneum. The superior pars vascularis of the corium exhibits 
enlarged vessels surrounded by inflammatory elements. 

When the nail is involved the parasite may be recognized in the 
debris produced by scraping the nail-substance ; often also in the epi- 
dermis bordering the nail. The fungus exhibits here the same micro- 
scopical features as upon the scalp, though in consequence of the denser 
structure of the nail-substance its vegetation is usually less luxuriant. 

Diagnosis. — The clinical recognition of favus is based upon the 
presence of the characteristic, yellowish, cup-shaped crusts, which in 
all typical cases are isolated, each pierced by a pilary filament and each 
situated in a well-marked depression of the surface of the scalp. In 
the disseminated form the disks of conglomerated scutella with defined 
and frequently festooned edges, friable, yellowish or yellowish white 
in color, and greatly differing as to their bulk and contour, are com- 
monly suggestive of the nature of the disorder. In yet other irregu- 
larly formed crusts the affected area seems to be covered with a plaster- 
like mass irregularly distributed and of uneven thickness over an 
enormous patch of disease which may be practically coextensive with 
the entire scalp-surface. Incidentally there may be a history of con- 
tagion and a peculiar odor emanating from the scalp. The secondary 
effects upon the hairs, hair-follicles, and skin are also, when present, 
significant. White, of Boston, in an essay on the " Vegetable Para- 
sites, and Diseases caused by their Growth upon Man," calls attention 
to the stage in which the disease is likely to be mistaken for ringworm. 
It exists before the formation of the crust, and may be characterized 
by hyperemia, vesiculation, or papulation, often unnoticed beneath the 
hairs of the scalp. In doubtful cases the microscope will usually estab- 
lish the diagnosis, though Bodin, Morris, Sabouraud, and other 
observers think it is not always possible to draw a sharp line between 
favus and ringworm, and that cases occur in which it is impossible — 
with the means now at our disposal — to make a differential diagnosis 
with precision. 1 

Aubert, 2 in the absence of the clinical features named above, lays 
stress upon an intense redness of the scalp where the hairs have been 
cut and the crusts removed, this color being limited to the portions at- 
tacked by the disease. The hairs also, as a result of disintegration 
of their elements, are infiltrated with air, and look opaque and black by 
transmitted light ; by reflected light they appear polished and stratified, 
as if constituted of layers of tissue. It should not be forgotten that 
in exceptional cases favus-crusts coexist upon the body with other dis- 
eases of prior or of subsequent origin, as indicated. The disease should 
not be confounded with seborrhoea, pustular eczema, or psoriasis of the 
scalp, none of which exhibits the special features of a parasitic fungus. 

Treatment. — The first indication in the treatment of favus is to 
cleanse the affected surface from all crusts and scales that may be 
present. For this purpose the scalp (if this be, for example, the 
affected part) is first shorn of its hair with scissors, and is then thor- 

1 For literature of this subject consult the references tabulated with the introductory 
paragraphs on Bingworm. 

2 Annal. de Derm, et de Syph., 2e. ser., ii., p. 34, 



TINEA FAVOSA. 735 

oughly soaked with olive-, cod-liver, or other oil, or with glycerin. 
After this treatment all the crusts are scraped away with a spatula, 
and the scalp is washed clean with hot water and soap, spirit of green 
soap being here preferably used. The scalp should then again be 
anointed with oil or be covered with an emollient poultice. Once thor- 
oughly cleansed by repeated soakings with oil and by ablutions, it is 
necessary to resort either to the topical employment of parasiticides 
(agents capable of destroying the fungus) or to epilation (extraction 
of the hairs). Often both measures are required. Without further 
treatment the scalp, however completely freed from all evidences of 
the disease, will not fail to show fresh favus-crusts in a fortnight or 
somewhat longer time. 

Epilation is practised with the aid of epilating-forceps. These for- 
ceps should be constructed with an easy spring that will not tire the 
fingers of the operator ; with blades that are sufficiently broad to grasp 
a few hairs at once ; and with smooth or but slightly serrated faces of 
the blades, as otherwise the hair is liable to fracture in the grasp of the in- 
strument. The surface to be operated upon should previously be anointed 
with vaselin or with olive-oil, and the hairs entirely be removed, a suf- 
ficient number, covering a definite space, upon successive days. 

The tediousness of this process has led to several devices by which 
it is sought to do away with its necessity. Originally the " calotte " 
was employed for the removal of the hairs ; it was made by smearing 
a disk of leather with pitch, and applying it over the scalp. When 
the calotte was subsequently removed by a brisk twitch with the 
hand the hairs which adhered were forcibly uprooted en masse; 
those remaining being adherent in their sacs in consequence of the 
fact that they had not been invaded by the fungus. As a substi- 
tute for this procedure, Bulkley * employed adhesive masses or sticks, 
which can be melted and be made to adhere at once to large numbers 
of the hairs. When cold they can be withdrawn from the surface 
with the hairs attached. These sticks are from two to three inches in 
length, and from one-fourth to three-fourths of an inch in diameter. 
The hair is first clipped so as to be about one-eighth of an inch in 
length. The end of the stick is then heated in an alcoholic flame, 
and quickly placed upon the scalp. It is thus left in place until cold, 
and is removed by bending it over and drawing upon the hairs suc- 
cessively with slight rotation. When free it is found thickly set with 
the extracted filaments, which may be burned off in the alcohol flame, 
thus destroying both the hairs and any adherent fungous masses. The 
stick is then carefully wiped clean with paper, after which it is again 
ready for use. The formula for the mass of which these sticks are 
composed is as follows : 

R Cerse flavae, 3iii ; 12 

16 
24 
44 
45 M. 

1 " Favus and its Treatment by a New Method of Depilation ," Arch, of Derm., 
April, 1881, vii., No. 2. 



Cerse flavae, 


3hj ; 


Laccse in tubulis, 


3iv; 


Kesinae, 


3vj ; 


Picis Burgundicae, 


3xj; 


Gummi dammar., 


Bjss; 



736 PARASITIC AFFECTIONS. 

The parasiticides in greatest favor are : corrosive sublimate in solu- 
tion in the strength of from 1 to 4 grains (0.066-0.266) to the ounce 
(30.) ; formalin (1 to 4 per cent.) ; sodium hyposulphite in saturated 
solution ; pure or diluted sulphurous acid ; spirit of green soap ; chry- 
sarobin, pyrogallol, tar, croton-oil ; boric, carbolic, and salicylic acids ; 
petroleum, chloroform, ether, creosote, and oil of cloves. The addi- 
tion of acetic acid to liquid applications, or washing the surface with 
vinegar immediately before applying the parasiticide, favors penetration 
of the remedy. Ointments are also useful containing mercury (citrin 
ointment, yellow sulphate, or white precipitate), naphtol, benzol, thy- 
mol, sulphur, pyrogallol, salicylic and carbolic acids. Chrysarobin 
is effective in an ointment, though objectionable on account of the 
staining of the scalp, and, almost inevitably, of the face also. Lenz- 
berg * generates sulphur-fumes in a dish of red-hot coals attached to a 
frame (made of wood or of pasteboard) close to the head of the patient. 
By means of a paper cap the fames are collected and retained (from 
five to ten minutes) in contact with the patient's hair. During ten 
years' trial of this plan he has never been compelled to resort to 
epilation. 

One or more of the methods may be needed, either at the same time 
or by repetition or alternation, until the fungus is entirely destroyed, 
the requisite period usually extending over three months. Treatment 
should then be discontinued in order to test the result by observation. 
If, in the course of a fortnight or more, a relapse occurs, treatment is 
to be promptly renewed. Upon the non-hairy portions of the body 
parasiticides thoroughly applied usually insure radical relief. When 
the nail is involved, it should be cut short and carefully scraped or be 
softened by repeated applications of a strongly alkaline lotion, after 
which a parasiticide may be employed in ointment or lotion. 

In general, it may be remarked that patients long affected with 
rebellious favus may need a roborant course of treatment and nu- 
tritious diet. Cleanliness here, as in all the parasitic disorders, is 
important. As adjuvants in the treatment of the scalp and nails it is 
well to remember that continuous applications of a parasiticide are 
aided by caps or cots of impermeable material superimposed upon rags 
saturated with the medicament employed. For use in this manner, and 
especially for the nails, Sabouraud recommends a solution containing 1 
gramme of iodine and 2 grammes of potassium iodide in a litre of dis- 
tilled water. 2 

Prognosis. — The prognosis is generally favorable to the ultimate 
termination of the disease in all cases ; for even the most rebellious 
and untreated forms are relieved when the hair-follicles atrophy. Upon 
the non-hairy portions of the body the disorder is rarely severe if 
promptly and efficiently treated. Upon the scalp the prognosis is pro- 
portioned to the extent, severity, and period of prior invasion of the 
disease. Early and vigorous treatment of the scalp in healthy children 
is usually followed by satisfactory results. In long-neglected subjects 
of the disorder the result may be a remediless and characteristic bald- 

1 Der prakt. Arzt., February, 1881. 

2 See paragraphs at the close of the chapter on Ringworm. 



PLATE XXIV. 



Fig. 1. 




Portion of a Hair showing the Mierosporon Audouini. 

(From]a photo-micrograph.) 



Fig. 2. 




Portion of a Hair invaded by the Trichophyton, 
Endo-Eetothrix. x SOO. 

a, a — Chains of spores in focus, b — A chain situated further within the hair, and hence not in focus. 

(From a photo-micrograph.) 



TINEA TR1CH0PHYTINA. 737 

ness, the affected surface being provided with scanty wisps of stunted 
and uncolored hairs. Neglect, filth, and systemic malnutrition are the 
most unfavorable elements in any case. 

TINEA TRICHOPHYTINA. 

(Gr. dpltj, hair ; ^>vt6v, a vegetation.) 
(RlNGWOEM.) 

Ringworm is a disease of the hairs and hair-follicles of the scalp 
and the beard, as also of the non-hairy portions of the body. In each 
case it is produced by the presence of a vegetable fungus. Until re- 
cently all forms of ringworm, both of the hairy and non-hairy portions 
of the body, were supposed to be produced by a single fungus, the 
trichophyton. In 1891 Furthmann and Neebe first advanced the idea 
that there were two or more fungi responsible for the various mani- 
festations of the disease. Within the last few years a number of in- 
vestigators, headed by Sabouraud, in a series of researches, have more 
definitely settled the etiological value of these fungi. 1 There are at 
least two distinct and unrelated forms capable of producing the 
appearances classed as ringworm : the Microsporon Attdouini, or 
small-spored fungus, and the Trichophyton, or large-spored fungus. 
Of the latter, several varieties are recognized. The microsporon appears 
under the microscope chiefly in the form of a large number of round 
spores, irregularly grouped or massed about the follicular portion of the 
hair. Mycelial threads, large and branching, are also seen, chiefly within 
the hair. The sheath of spores surrounding the hair is often continued 
upward about the latter for one-sixteenth or one-eighth of an inch 
above its exit from the follicle, and in this situation can be recognized 
by the unaided eye as a whitish or grayish coating of the hair. 

The mycelial threads of the microsporon are all within the hair 
proper, and after repeatedly dividing and subdividing they terminate 
on the outer surface of the shaft in fine filaments, at the extremities of 
which are the spores, which in this fungus are external. In France 
the microsporon is responsible for about 60 per cent, of all cases of 
ringworm of the scalp in children. The fungus is not found in ring- 
worm of the beard or of the body except in the form of small, irreg- 
ularly outlined, slightly reddened, and furfuraceous patches, occurring 
on the face and neck in children having ringworm of the scalp ; occa- 
sionally on the skin of adults who come in contact with such children. 

1 Sabouraud : Les Trichophyties humaines, with Atlas. Paris, 1894. Diagnostic et 
traitement de la pelade et desteignes de l'enfant. Paris, 1895. Adamson : Brit. Jour, 
of Derm., July, Aug., and Dec., 1895. Morris: Practitioner, Aug., 1895. Ringworm 
and the Trichophyton. London, 1896. Fox and Blaxall: Brit. Jour, of Derm., July, 
Aug., Sept., and Oct., 1896. Transactions of Third International Congress of Derma- 
tology, London, Aug. 4 to 8, 1896. Papers by Sabouraud, Rosenbach, and Morris. 
Rosenbach : " Ueber die tieferen eiternden Schimmelerkrankungen der Haut." Wies- 
baden, 1894. Leslie Roberts : Brit. Therap. Jour., Sept. 29, 1894. Jour. Path, and 
Bact., Aug., 1895. This observer classifies the fungi according to their ability to digest 
horny tissues. M. Fadyen : Jour. Path, and Bact., April, 1895. Jamieson: Brit. 
Med. Jour., Aug. 20, 1893. Bodin: Des Teignes tondantes du cheval et leur inocula- 
tions humaines. Paris, 1896. Mibelli : Annal. de Derm, et de Syph., 1895, p. 733. 
Charles J. White : Jour. Cutan. and Gen.-Urin. Dis., Jan., 1899. 

47 



738 PARASITIC AFFECTIONS. 

Such lesions of the skin do not at all resemble ordinary ringworm, as 
their outlines are irregular and ill denned, and they rarely persist for 
more than a few days at a time. Iu France the microsporon is rarely, 
if ever, found in kerion. 

The trichophyton is composed of spores which vary greatly in size, 
but which, as a rule, are considerably larger than those of the micro- 
sporon. They are frequently cuboidal, oval, or irregularly rounded ; 
but their chief characteristic lies in the arrangement in lines or chains 
extending up and down the hair-shaft. The mycelium is found without 
but never within the hairs. The trichophyton occurs in three varie- 
ties : the endothrix, in which the spores occur wholly within ; the ecto- 
thrix, in which the spores are distributed wholly without ; and the endo- 
ectothrix, in which the spores are partly within and partly without the 
hair. The endothrix, like the microsporon, is found only in ring- 
worm of the scalp of children, though it also may produce transient, 
inconspicuous, irregular, furfuraceous, and slightly reddened patches 
on the face and neck of children affected with this form of ringworm. 
On the scalp the endothrix produces lesions which are often distinctly 
different from those caused by the microsporon. These differences are 
noted in the clinical description of tinea tonsurans. The ectothrix and 
the endo-ectothrix apparently are derived either directly or indirectly 
from the domestic animals, and are responsible for ringworm of the 
body, of the beard, and of all suppurating forms of the disease. By 
means of culture-experiments a number of subvarieties of the tricho- 
phyton are differentiated, many of which, however, are not generally 
accepted. These varied appearances are looked upon by some as the 
result largely or wholly of differences in the media and circum- 
stances of cultivation. It is well known that slight modifications of 
the culture-media produce marked changes in the character of a fungus- 
growth. 

In London, Morris, Fox, Adamson, and others find that the micro- 
sporon is responsible for more than 90 per cent, of all cases of ring- 
worm of the scalp in children, and that it also occurs in some cases of 
ringworm of the body, and even in some of the suppurating forms of 
the disease, as kerion. The trichophyton is comparatively rare in Lon- 
don. On the other hand, Mibelli states that the microsporon is almost 
unknown in some parts of Italy, and it would seem to be equally rare 
in some portions of Germany. In Boston Dr. Charles J. White found 
the microsporon in 139 out of 279 cases of ringworm examined. The 
different varieties of these fungi seem to have a definite geographical 
distribution. 

To prepare a hair for examination, it may be placed between a 
slide and cover-glass in a solution of potassium hydroxide. Sabouraud 
uses a 25 to 40 per cent, solution, which is admirable for rapid work, 
but which quickly disintegrates the hair. Adamson employs a 5 or 10 
per cent, solution, which clears the hair slowly in the course of one or 
several hours. By making frequent examinations of the specimen the 
observer can arrest the destructive action of the solution at any stage 
desired, and thus better preserve the relative position of the fungus to 
the hair. Many attempts have been made to stain the fungi, which 



i 



TINEA TRICHOPHYTINA. 739 

unfortunately show an affinity for the same stains as does the cortical 
layer of the hair. A satisfactory method has been devised by 
Morris and his laboratory assistant, Calhoun. It is a modification of 
the Gram and Weigert stain for bacilli, and gives good results. The 
hair is first washed with ether to remove fatty debris ; it is then put for 
one or two minutes in the Gram iodine solution, and after drying is 
stained for from one to five minutes in gentian-violet and anilin-water. 
It is again dried and treated for a minute or two with the iodine solu- 
tion, and for an equal length of time in anilin-oil containing pure iodine, 
after which it is cleared with anilin-oil, washed in xylol, and mounted 
in Canada balsam. Coarse, dark hairs and spores within the hairs 
require more time for staining than do fine, light-colored hairs and the 
fungus-elements situated without the hair. 

While microscopical examination will often suffice to distinguish 
the microsporon from the trichophyton, or even for recognition of some 
of the varieties of the latter, the finer — and often disputed — points of 
difference can be appreciated only by means of culture-experiments, 
the details of which require fuller description than can here be 
given. 

Recent studies of the ringworm fungus, though interesting from 
an etiological standpoint, have added little knowledge of practical 
value in treatment of the disease, nor have they furnished a basis for a 
new and scientific classification of the different forms of ringworm. 

As the several regions of the body, when invaded by the parasite, 
display lesions which are more or less peculiar to itself, it is usual to 
consider each separately. Ringworm of the body is, therefore, desig- 
nated Tinea Circinata ; of the scalp, Tinea Tonsurans ; of the 
beard, Tinea Sycosis. 

Tinea Circinata. 

(Herpes Tonsurans, Ringworm of the Body. Ger., Scheerende 
Flechte ; Fr.j Herpes circine, Tricophytie.) 

Symptoms. — Ringworm of the body displays different symptoms 
according to the temperature in which the vegetation flourishes and 
the various external irritants to which the skin where it has once been 
implanted is subjected. 

The macular form of the disease is characterized by the occurrence 
of one or of several pea- to large coin-sized, circumscribed, reddish 
circles, usually paling under pressure, often at the general level of the 
integument, occasionally slightly raised above it, forming then a flat- 
tened disk. The centre of the circle may be paler, or indeed to the 
naked eye be unaffected, transforming the patch to an annular lesion, 
from which circumstance it originally received the name " ringworm." 
It develops within certain limits, rarely exceeding five or six inches in 
diameter, by peripheral extension ; and is usually characterized at the 
outer border by slight, whitish, furfuraceous desquamation. This form 
of lesion is usually seen upon exposed surfaces of the body where there 
is less heat, moisture, and friction than upon other parts, as, for exam- 



740 PARASITIC AFFECTIONS. 

pie, the forehead and neck in moderate atmospheric temperatures. 
From it may be developed the other forms described below. The 
disease may recur within the peripheral border; in this way occasionally 
two, three, or more concentric rings or parallel bands of crescentic 
outline may be visible in a single patch of disease. Frequently a ten- 
dency to a peculiar formation, often that of concentric circles, is found 
in every patch existing at the same time in a given case. It is possible 
that the various types are produced by different species of the fungus. 
The subjective sensations are a trifling degree of itching or of burning. 
Should these rings extend to the beard or the scalp, the circinate may 
coexist with the other varieties of the disease. 

The vesicular lesions of ringworm appear as such at the onset, or 
they rise from the macular lesions described above. In the former 
case pin-point-sized, transitory, and superficial vesicles or vesico- 
papules spring from a central point or focus, or speedily shrivel until 
they are represented merely by minute, whitish, branny scales. To 
these lesions others succeed, always at the periphery, and to these again 
yet others, the rosy or the reddened base on which they rest being 
sometimes slightly in advance toward the outlying skin. The enlarg- 
ing circlets of disease proceed in their course to an evolution similar to 
that observed in the macular forms. The difference, due to a more 
active development of the fungus, is noted not merely in the type of 
the lesion, but also in the slightly exaggerated pruritic sensations 
that are awakened. Rarely, both of the forms described are pre- 
sented with acute symptoms and extensive development, in multiple 
patches spreading over the face, neck, trunk, and extremities, accom- 
panied by a slight febrile movement and moderate tumefaction of 
the affected surfaces. As a rule, the eruption is trifling, and may, in- 
deed, be limited to a single ring, or to a few circlets about the neck, 
terminating in the branny desquamation described ; but in the severer 
forms the evolution of the disease may persist for months and crusts 
form, the fall of which leaves annular pigmentations of temporary 
duration. 

The papular and rare pustular forms of the disease observe the same 
peculiarities with respect to the clearing of the centre, the annular 
appearance of the advancing area of involvement, and the production 
finally of scales and crusts. They represent, however, either a much 
more luxuriant vegetation of the fungus, or the irritation of the affected 
part by friction and heat, or, what is probable, the cooperation of the 
two. They are, hence, most commonly observed upon the back, the 
belly, the intermammary and inframammary regions, and the inner 
faces of the thighs and arms, in which localities they occasionally 
occur with chronic manifestations. The papules are light- or dull-red- 
dish, pinhead-sized and larger, solid elevations, roundish, oval-shaped, 
irregular, or confluent, forming eventually bean- to coin-sized, raised 
disks with a pale, exfoliating, or actively inflamed centre, the so-called 

NUMMULAR ERYTHEMA, or DISCOID TRICHOPHYTIC ERYTHEMA of 

French authors. Some of the cases of Conglomerate or Agminate 
Folliculitis are due to the trichophyton. The itching in these forms 
is sometimes severe ; and the process may display central recrudescence, 



TINEA TRICHOPHYTINA. 741 

as noted above. Pustules found at the periphery have the size and 
distribution of the other lesions described. They represent merely 
an aggravated exudative process awakened by the fungus and the 
scratching incident to the pruritic sensations excited. 

Eczema Marginatum, Tinea Trickophytina Cruris. — Partly 
because of the controversy which the subject aroused, special attention 
was once directed to this variant of the disease which Hebra was first 
to describe. It is most marked upon those portions of the body which 
come in contact with the saddle when a rider is mounted on a horse — 
that is, the perineum and the inner faces of the thighs, the region 
marked by the reinforcing patch in the trousers of the cavalry- 
man. The disease, as encountered here, occurs in both sexes. It is 
characterized by extensive exudation in bright or lurid patches, with a 
very distinctly defined, raised border, showing a sharp contrast with 
the healthy skin beyond, from which peculiarity it has its name. It 
may extend laterally over the groins upward over the pubes, and back- 
ward over the sacrum, being generally defined at the periphery by a 
crescentic outline. The centre may be paler and less involved, or 
actively irritated, while the periphery still extends in one or more 
annular festoons down the inner side of the thigh or upward over 
the regions indicated. The itching is severe ; the course of the dis- 
ease is obstinate, persistent, and subject in a remarkable degree to 
1 relapse in the same locality. The fungus is always present, whether 
1 occurring as a cause or an epiphenomenon of the disorder. The dis- 
\ ease was rightly named by Hebra, and it deserves special recognition 
J under whatever title it may be classified. It is a true eczema, with 
special features, complicated by the development of the trichophyton, 
and, as is now well known, often by other representatives of the " der- 
matological flora." It is aggravated by heat, the moisture of sweat, 
and the friction of apposed surfaces of the skin in contact with 
each other and the clothing. After detecting the fungus in scales 
scraped from the surfaces thus involved, one is always in such cases 
impressed with the characteristic clinical peculiarities of the disease. 
! It is usually of symmetrical distribution, due to the circumstances of 
its development, and in this respect differs from the other manifesta- 
tions of the disease. The condition may occur in milder or even 
severe forms in the axilla or about the breasts of women or about 
the umbilicus. In such cases it is indistinguishable clinically from 
a disorder described by Vidal under the title Circinate and Mar- 
ginate Pityriasis (pityriasis circine et margine), which he regards as 
due to the microsporon anomceon, or dispar. 

Tinea Trichophytina Unguium (Onychomycosis). — When the 
nails are affected they become friable, opaque, and lamellated ; and 
are clinically indistinguishable from nails secondarily changed in favus, 
eczema, psoriasis, and similar disorders of the integument. One or 
several of the nails of both the feet and hands may be involved. 
When all the nails of both extremities are invaded the disease is rarely 
of parasitic origin. The microscope is requisite for establishing the 
diagnosis in the latter case, the parasite being detected in the frag- 
ments procured by scraping the nail. 



742 PARASITIC AFFECTIONS. 






Etiology. — Tinea circinata is caused by the presence of the parasite, 
though the parasitic invasion may be an accident of other cutaneous 
disorders. The trichophyton was first discovered in 1844 by 
Gruby ; though Malrnsten, whose name is often associated with that 
of the fungus, became identified with its recognition by his observa- 
tions during the succeeding year. As a contagious disease it ranks 
higher in the scale than favus, being much more readily communicated, 
and, as a result, much more common. Occurring upon the non-hairy 
portions of the body, it is often spontaneously removed by the desquam- 
ative process which it excites in the skin. 

Though the fungus is the essential cause of the disease, its develop- 
ment is greatly favored or retarded by external influences. Attention 
has already been called to its luxuriance under the influence of heat 
and moisture. It is, therefore, much more severe and rebellions to 
treatment in tropical countries. It occasionally occurs in epidemic 
forms. Thus, Gerlier 1 gives the details of such an epidemic in Fer- 
ney Voltaire, where twenty-six cases of the disease came under his 
observation. In some of these instances the lesions were pustular, 
in other tuberculo-pustular. Aggravated forms of the disease often 
originate in the lower animals, the severest and most rebellious 
types being derived usually from the horse. Tinea circinata oc- 
curs much more frequently in children than in adults, presumably 
from the relatively tender condition of the epidermis in these subjects. 
It is particularly liable to occur in men whose skins are especially 
moistened, as in those who work in atmospheres saturated with steam. 
Several members of a single household will often display ringworm 
of the body at the same time, having transmitted it the one to the 
other. The need of an appropriate soil for the germination of the 
fungus is shown by the fact that some individuals are predisposed to 
its invasion. It is, however, encountered in both sexes and in all 
social conditions. 

Pathology. — The seat of the fungus in tinea circinata is between the 
strata of the epidermis, more particularly in the lower layers of the 
stratum corneum and in the superior layers of the rete. Here the 
trichophyton can be recognized with the microscope, at an early stage 
of the disease, in the form of spores only ; in the course of a few 
weeks exhibiting characteristic mycelium. The latter is much more 
scantily developed than in favus ; much less branched and articular ; 
and the threads more slender. Like the elements in favus, however, 
these are jointed and divided into compound cells by partition-walls. 
The spores are also often strung like beads on a necklace. The former 
measure 0.0018 to 0.0026 mm.; and the latter, 0.0021 to 0.0035 mm. 
(Duhring). 

After the fungus has found its way to the surface of the skin favor- 
able to its development it penetrates the layers of the epidermis in 
every direction from the central point of invasion, the circle thus pro- 
duced being characteristic of many forms in both the higher and the 
lower vegetable life. The irritation excited by the presence of this 
foreign body produces all the subsequent symptoms of a mild grade of 

1 Lyon m€d., April 24, 1881, p. 590, and May 2, p. 7. 



TINEA TR1CH0PHYT1NA. 



743 



superficially seated inflammation : erythema, exudation, minute vesicles, 
papules, and, in severe grades, tubercles and pustules. The desquama- 
tive symptoms represent, in a sense, the natural effort at relief; 
this effort, as noted above, being often successful when the spores and 
sporophores are thrown off with the effete, horny plates of the epi- 
dermis. When the nails are affected the fungus can be discovered 
in detritus of the nail-tissue which has been macerated in dilute 
liquor potassse. Sabouraud states that only the different species 
of trichophyton, ectothrix pure, or endo-ectothrix, are found in ring- 
worm of the glabrous skin and of the nails, though the trichophyton 
endothrix and the microsporon Audouini may be found occasionally 
in small, irregular, transient, reddened, slightly furfuraceous areas 
occurring on the face, neck, and other parts of the body during the 
course of ringworm of the scalp. 



Fig. 89 




Epidermis invaded by trichophyton : a, inferior portion of the stratum corneum ; b. superior 
portion of the rete. Both exhibit long mycelial threads, with a few ramifications and a small 
number of spores. (Kaposi.) 



Diagnosis. — Ringworm of the body is to be distinguished, clinically, 
from eczema, psoriasis, seborrhoea, lupus erythematosus, herpes iris, and 
syphilis. All the varieties of eczema are noted for their greater degree 
of itching and infiltration, their much less defined border, coarser 
scales, decided absence of a circular contour and of a history of con- 
tagion. Psoriasis does occur in circular and annular patches, often 
with a clear centre and insignificant, subjective sensations ; but its scales 
are lustrous and the tissue beneath them readily bleeds, showing 
deeper implication of the skin. The disease is often symmetrical in 
disposition ; occurs by preference upon certain regions of the body 
where ringworm is relatively infrequent ; and its history is that of a 
chronic disorder. Seborrhoea of the skin exhibits greasy or fatty crusts, 
which are never characterized by the peculiarly branny scales seen in 



744 PARASITIC AFFECTIONS. 

ringworm of the body. (The distinction between these disorders on 
the scalp is given under Tinea tonsurans.) Lupus erythematosus is 
often symmetrical, generally chronic, and is characterized by the develop- 
ment of multiple annular patches, enlarging centrifugally from a clear- 
ing centre. Herpes iris can be distinguished, first, by its predilection 
for the extremities ; second, by the color- variegations which it displays 
and which are never seen in ringworm of the hands. Syphilis is mul- 
tiform in its lesions, usually preceded by a history of infection ; and 
its distinctly circular patches, enlarging at the periphery, all exhibit 
either atrophic, ulcerative, or distinctly crusted lesions which suffice 
for diagnostic purposes. 

Pityriasis rosea is not characterized by vesicles ; is often symmet- 
rical in development ; occurs in oval rather than in distinctly circular 
patches ; and exhibits a characteristic tawny-yellowish shade of color 
not seen in ringworm. In eczema marginatum the elevated border and 
infiltration of the diseased surface, its situation (groins, armpits, pubes, 
etc.), its curved outlines, and the occurrence of fresh rings within the 
older, point to the nature of the trouble, which is practically a coexist- 
ence of ringworm and dermatitis. 

But the microscopical discovery of the parasite is the chief, and, 
indeed, the essential, method of diagnosis in tinea circinata. With 
a good fourth- or fifth-inch objective the spores and mycelium are 
readily recognized in the scales scraped from the affected surface 
and moistened with dilute liquor potassse. Care should be had in 
distinguishing the fungous elements from cotton- or wool-fibres, fat- 
globules derived from previously applied unguents for the cure of the 
disease, sebum, pus, and the nuclei of epithelia. All confusion of this 
sort can be avoided by a careful study of the anatomical peculiarities of 
the trichophyton, recalling especially the parallelism seen in the double 
contours of the threads, their jointed appearance, their contained 
granules, and the necklace-like or beaded arrangement of many spores. 

Treatment. — The indications in the treatment of ringworm of the 
body are the removal of the superficial layers of the epidermis, by 
which means the spores and mycelium are thrown off from the surface ; 
and, if possible, the simultaneous destruction of the latter. Upon the 
delicate skins of infants and children the simpler remedies are first to 
be employed. Scrubbing each patch with spirit of green soap, or merely 
soap and water, will often suffice for its obliteration. The topical ap- 
plication of tincture of iodine is a common and usually an effective 
remedy. The same may be said of dilute acetic, boric, and carbolic 
acids, or of a 1 or 2 per cent, solution of formalin. A solution of acetic 
acid used with or immediately before other parasiticides is said to favor 
penetration of the latter. Morris's solution of thymol, 1 ^ drachm to 2 
drachms (2.-8.) of chloroform and 6 drachms (24.) of olive-oil, is equally 
available. One may also use thymol in ointments, -^ drachm (2.) to 
the ounce (30.) of simple unguent, with good effect. A 1 to 2 per cent, 
solution of formalin is often effective. Of the mercurials, ammoniated 
mercury, 1 scruple (1.33) to the ounce (30.) of ointment ; corrosive sub- 
limate, 1 to 2 grains (0.066-0.133) to the ounce (30.) of solution ; and 

1 Lancet, 1881, pp. 164 and 241. 



TINEA TRICHOPHYTINA. 745 

the ointment of mercuric nitrate, 1 drachm (4.) to the ounce (30.) of 
vaselin, are valuable. Sulphurous acid, from a freshly opened can, and 
saturated solutions of sodium hyposulphite are as eifective as any of 
the parasiticides, and are often used with advantage as lotions, to be 
followed by an appropriate unguent, always providing against chemical 
decomposition of the ingredients of the latter. Sulphur- and tar-con- 
taining lotions and unguents are useful in more obstinate cases. 

Chrysarobin and pyrogallol, in ointment, from 5 to 10 grains (0.33- 
0.66) to the ounce (30.), are brilliantly effective in all these cases, sub- 
ject, however, to the disadvantage incidental to the staining and irri- 
tative effects they produce. They should be used with caution upon 
the skins of children, and always tentatively at the onset. In cases of 
ringworm of the face of male adults, close to the beard or the scalp, one 
may employ these remedies with a view to insure non-invasion of the 
pilary follicles by the fungus, the prompt destruction of which may 
become then a matter of urgency. Wilkinson's ointment recommended 
by Kaposi is also useful in the treatment of aggravated forms of ring- 
worm of the body, but it should be restricted to such forms. For other 
and more urgent reasons potassium hydroxide solutions should be re- 
served for exceedingly intractable cases. Sometimes a combination of 
several of the simpler remedies named above may be serviceable, as in 
the following formulae : 

R Lac. sulphur., 3ijss; 10 

Sapon. virid. spts., \ .. _ . . -- 94 

Lavandul. tr., } aa 3v J ' aa ^ 

Glycerin., 3 SS ; 2 M. 

[Kaposi.] 

R lodin. pur., Jij ; 601 

01. picis [sp. gr. 0.853], % j ; 30) M. 



Mix with care, gradually. 

R Creasoti, tt\,xx; 1 

01. cadini, f 3iij ; 12 

Sulphuris prsecip., f giij : 12 

Potass, bicarb., 3j ; 4 

Adipis, ^j ; 30 



33 



M. 



To be used in obstinate ringworm of adults. 



[Van Harlingen.] 



R. W. Taylor applies mercuric chloride, 4 grains to the oiuice 
(0.26-30.) in tincture of myrrh. Perry, of California, uses the bichlor- 
ide in one-half the strength last named, dissolved in sulphuric ether. 
Foulis, of Edinburgh, recommends iodine dissolved in oil of turpentine 
or benzin, the fluids named penetrating with greater ease than others 
to the deeper portions of the skin. 

Other articles advised are oleates of mercury and copper, croton-oil, 

[glacial acetic acid, cantharidal collodion, petroleum, and pyroligneous 
acid (Thomas). 

The thorough application of the remedy selected for use, upon 
the integument freed from scales by scrubbing with soap and water, 
is a matter of importance. When a solution of sodium hyposulphite 



746 PAUASITIC AFFECTIONS. 

is employed, the previous application of vinegar and water by 
sponging renders the agent more effective, for evident chemical 
reasons. Over-treated skins, or those to which too strong a parasiti- 
cide has been applied, require subsequent relief of the induced irrita- 
tion by the simpler bland dressings. The inert dusting-powders, even 
when not thus indicated, are often useful when there is distinct 
vesiculation ; and in simple cases they may be the sole remedies re- 
quired, as then the disease is self-limited in duration. 

The internal treatment of patients affected with ringworm, by means 
of tonics and roborant measures, may be demanded by the systemic 
condition, but it has no recognized influence over the disease itself. 

When the nails are involved, they should be thoroughly scraped 
and then kept moist by wearing the rubber cots sold for the use of 
sportsmen, fishermen, and others. In this way a partial maceration of 
the nail-substance is secured, and the action of any one of the para- 
siticides named above is greatly aided. One of the solutions most 
useful in the treatment of the nails is that recommended by Sabouraud, 
containing 1 gramme of iodine and 2 grammes of potassium iodide in 
a litre of distilled water. 

Prognosis. — The disease is often self-limited, and is generally 
under the simplest treatment satisfactorily relieved. Eczema margi- 
natum, especially in the crural region, may be obstinate, because it is an 
eczema as well as a parasitic disease, and, therefore, subject to the re- 
lapsed and chronic phases of the first-named disorder. Other intract- 
able forms of the malady do, however, occasionally occur in adults, 
usually in tropical climates and tropical temperatures. 

Tinea Tonsurans. 

(Ringworm of the Scalp, Herpes Tonsurans, Tinea Tondens. 
Ger., Scheerende Flechte ; Fr., Teigne Tondante.) 

Ringworm of the scalp is a disease chiefly of children, and occurs 
most frequently among those congregated in public institutions. The 
gregarious habits of children and the frequency and intimate character 
of contacts in their amusements and studies greatly increase the 
chances of contagion when one of their number is affected with ring- 
worm of the scalp. As a consequence, the early recognition and 
relief of the disease furnish problems among the most imperious pre- 
sented to the general practitioner as well as to the dermatologist. 
Important considerations relating to the segregation and education 
of children are wrapped up with the question of treatment. Nor 
should the physician, examining and giving advice about the scalp of 
a number of children, forget that his hands may transmit the disease 
to those as yet unaffected. 

Symptoms. — The differences to be particularly noted between ring- 
worm of the body and ringworm of the scalp depend largely upon the 
fact that in the latter the fungus makes its way to the hair-follicles 
and there finds the nutriment for its multiplication and development. 
The symptoms usually first observed are circumscribed, small coin-sized, 



TINEA TRICHOPHYTINA. 747 

roundish patches upon the scalp, wholly or partly covered with minute, 
whitish, slate-colored, grayish, or dirty-yellowish scales. Sometimes 
the formation of the scales can be observed as they develop upon a 
hypersemic and reddened area. Still more rarely, pin-point-sized, 
transitory vesicles or pustules precede. The hairs upon such a patch 
seem irregularly clipped short near the surface or, as it is frequently 
styled, " nibbled " oif, thus producing the effect of partial baldness in 
the involved area. Among them may often be found lustreless, dry, 
long and fragile hairs, which break upon slight traction or flexion. 
The patches may increase in number and spread individually in area 
until, in the course of weeks or months, the entire scalp is invaded. 
In the older patches young and downy hairs may here and there be 
seen, pushing up the stumps left by those that have fallen. One or 
more of various phases of the disease may be presented in its subse- 
quent evolution. Thus, a single patch may extend to the size of that 
of a large coin or of the palm, and the disease be throughout limited to 
that area. Again, as set forth above, almost the entire scalp may be 
covered with relatively small or enlarging patches, or, even without the 
I occurrence of any distinct patch, isolated hairs or tufts of hairs here 
1 and there over the entire scalp may exhibit evidence of impairment. 
The hairs, instead of " starting " from the patch, may be twisted, 
imbricated, or matted, and be covered with grayish scales. The disease 
may be acute or be chronic in its course. Instead of assuming the dry 
and squamous type described, acute and exudative symptoms may de- 
velop, in which event the rare vesicular and pustular lesions are suc- 
ceeded by the exudation of a gummy secretion and the formation of 
crusts. Lastly, there may be produced the variety known as " kerion," 
which is described below. 

Pruritus, in various grades of severity, though usually mild, is in- 
duced by the disease ; and often the patches are altered in appearance 
by the traumatisms produced by the finger-nails and the comb. When 
the scalp is very generally invaded by the squamous form of the dis- 
order its appearance is very similar to that noted in diffuse seborrhoea, 
chronic eczema, and psoriasis of the scalp, except that the hairs are 
less pasted to the surface ; are more lustreless, friable, and contorted 
in shape ; and much more often are represented by stubble or stumps. 
The disease may occur coincidently with ringworm of the body, and 
indeed at times there may be detected a ring, half of which on the 
neck presents the typical aspect of tinea circinata, and the other half 
involving the scalp exhibits the features here described. 

Stowers, 1 Sangster, 2 as also Hutchinson, Tay, Hillier, Baker, and 
others, have recorded cases in which the disease coexisted with alopecia 
areata. Geber asserts that after exfoliation of patches of ringworm the 
scalp may, in cases, become absolutely bald, smooth, and glossy. This 
condition may exist from the beginning in the Bald Tinea Tonsurans 
of Liveing, which is often mistaken for alopecia areata, an error readily 
corrected by the recognition of scaling patches with hairs exhibiting 
under the microscope evidences of the existence of the fungus. It is 
to be remembered that in all such persistent scaling patches left after 
1 Lancet, 1881, p. 326. 2 Ibid., 1880, p. 303. 



748 PARASITIC AFFECTIONS. 

treated or untreated ringworm of the scalp the possibility of contagion 
is not averted. 

The Disseminated Ringworm of Alder Smith affects isolated 
hairs or small groups of hairs scattered over the scalp, a broken stump, 
or a group, or a relatively small number, of lustreless, dry, and friable 
hairs furnishing the only evidence of the disease. 

Ringworm produced by the microsporon Audouini can often be 
distinguished clinically from that produced by the trichophyton. In 
the former the patches are single or few in number, are rounded 
or oval in outline, may be of considerable size, are usually slightly 
reddened and furfuraceous, and are more or less covered with hairs 
which are lustreless, dirty looking, broken off at irregular distances 
from the surface, and easily epilated between the thumb and finger 
in considerable numbers. Moreover, in this form a grayish or 
whitish sheath (composed of spores) is seen encircling each hair 
and extending from one to three millimetres above its exit from 
the follicle. In patches of riugworm produced by the trichophyton, 
according to these observers, the patches are much more numerous, but 
are very small and irregular in outline, and instead of being covered 
by hairs and broken stumps of hairs, usually show a number of black 
dots at the mouths of the follicles caused by the breaking of the hair at 
or beneath the surface of the skin. In this latter form of ringworm 
the scalp itself is usually normal or nearly so, scaling not being usual ; 
and, instead of forming patches, the disease may affect isolated hairs 
or small groups of hairs. The disseminated ringworm and the 
bald tinea tonsurans mentioned above are probably produced by 
the trichophyton, and not by the small-spored fungus. It is un- 
doubtedly true that the clinical differences mentioned above can be 
noted in some cases, and the diagnosis made at once from a simple 
inspection of the affected areas. In the majority of cases, however, 
the clinical features are not sharply marked, and the diagnosis must 
rest upon microscopical examination, or even upon culture-experiments. 

Lastly, it is to be noted that in tinea tonsurans at times the efforts 
of nature are successful in obtaining spontaneous relief. With the 
defluvium capillitii and exfoliating epidermal plates the fungus may 
finally be removed ; the resulting alopecia be followed by a growth of 
healthy pilary filaments ; and, even though years be required for this 
long process, in the end no trace of the disease be discernible. 

Etiology. — Ringworm of the scalp is produced by the fungus recog- 
nized in the etiology of tinea circinata, the trichophyton, or by the 
microsporon Audouini. 1 Ringworm is frequently observed in children 
of both sexes, especially in those gathered together in schools and 
public charities, where it may spread very generally from one to 
another, and require months and years for its extermination. It is a 
highly contagious disease, but yet requires unquestionably a suitable 
soil for its development. White 2 calls attention to the fact that when 
there is ringworm on the face of an adult, even of rebellious form, in 
the course of which the beard may extensively be affected, the scalp is 
usually spared. Ringworm in the scalp of the adult and the aged is, 

1 See introductory paragraphs on Ringworm. 2 Loc. cit. 



TINEA TRICHOPHYTINA. 



749 



indeed, among the rarest of cutaneous accidents. Among the methods 
of transmission in children are the use upon the head of the unaffected 
of brushes, combs, wearing-apparel, sponges, towels, etc., which have 
been employed upon persons exhibiting ringworm of the body or the 
head. It must be remembered that tinea circinata may transmit tinea 
tonsurans ; and it is by tracing the course of the two forms of the dis- 
ease that the sources of contagion can be ascertained in any series of 
cases. The disease is one rather prevailing in cities than in the country ; 
in this respect it differs from favus. 

Pathology. — The disease is produced in consequence of invasion 
of the scalp and follicles, bulbs, and shafts of the hair by the fungus 
already described. 

Under the microscope the hairs are seen to be greatly altered 
in advanced cases (Fig. 90). The bulbs are distorted, misshapen, 

Fig. 90. 




Hair invaded by the trichophyton. 

or withered, and often stuffed with spores which greatly predomi- 
nate over the mycelium. At times the base of the bulb will show 
a brush-like expansion, and in this respect resembles the free ends of 
the stumps of the hairs above, which have a jagged, bristle-like appear- 
ance, from division of the shaft into many filaments between which 
spores in abundance are visible. The shaft is often longitudinally split 
where the parasitic growth has mechanically forced apart its elements, 
and its cuticle may be peeled off or curled above and below away 
from the axis, with spores protruding at such points. Conidia can 
be discovered much further upward along the hair and distant from 
the scalp than in favus ; often, indeed, upon its free surface. Occa- 
sionally a few mycelial threads may be recognized, either longitudinally 
or transversely arranged as regards the axis. It is probable, however, 
that the relative preponderance of spores and mycelium in these fila- 
ments is determined by the stadium of the disease in any given case. 
In the earlier stages of the affection the elongated threads may be dis- 
covered in larger quantity, and, as they interfere less with the integrity 
of the fibrous tissue, the hair usually at these times may be extracted 



750 PARASITIC AFFECTIONS. 

from its follicle without fracture. Later, the threads disappear and the 
conidia are infiltrated throughout every portion of the shaft, which 
then breaks often upon the slightest traction. One unaccustomed to 
microscopical examinations with a view to the detection of the parasite 
should be careful not to mistake for these threads the delicate lines 
which traverse the surface of the shaft exposed to the objective, and 
which represent the edges of the cuticle of the hair. In doubtful cases 
the hair should be examined in liquor potassse and after staining by the 
methods given in the first pages devoted to the subject of ringworm. 
The scales found upon the affected scalp also exhibit traces of the para- 
site under the microscope, though to a less extent than the invaded 
hairs. In exceptional cases, however, the epidermis of the scalp seems 
to suffer as much as that of the non-hairy portions of the body. 

As to the mode of invasion, it is still disputed whether the spores 
find access to the fundus of the follicle between the shaft and the 
follicular wall, or by penetrating the cuticle of the hair-shaft at the 
level of the epidermis. It is possible that invasion may occur in both 
ways. 

Diagnosis. — The recognition of a typical patch of ringworm of the 
head is simple. The branny scales, clumps of hairs, and distinct con- 
tour of the invaded area are always in the highest degree suspicious 
symptoms. It has been stated, however, that the general development 
of tinea tonsurans over the scalp produces a condition very like that 
seen in other diseases. In this case the microscope must be employed 
for a decision as to the nature of the process. The whole vertex has 
been unnecessarily epilated in seborrhoea sicca when no parasite could 
be found ; but in seborrhoea there is usually a symmetry of involvement 
which even aggravated cases of ringworm of the head fail to assume ; 
and even though pasted down, atrophied, changed in color, and loos- 
ened in their follicles, the hairs are rarely broken off near the scalp in 
seborrhoea. In seborrhoea, psoriasis, and squamous eczema of the scalp 
there is, moreover, no history of contagion ; the scales are in each 
disease different in color and character ; and the hairs in the two affec- 
tions last named are firmly fixed in their follicles, and only in severe 
cases present nutritional changes. The diseases, moreover, are usually 
chronic in their course. In any doubtful case, apart from microscopical 
evidence, thorough removal of all scales from the scalp by shampooing 
with green soap and hot water will reveal the nature of the disease ; 
present. 

Alopecia areata, as has been noted above, may coexist with ring- 
worm, but it is pathologically distinct from it. The patches in the 
first-named disease are uniformly smooth, and the hair falls from them 
en masse without scaling or other traces of previous involvement of the 
regions affected. Blackish points or dots may, however, be distributed 
over the areas which characterize this form of alopecia, and which cer- 
tainly constitute suspicious symptoms in any case. In this event one 
may at times be able to pick out with a fine needle this blackish point 
from the patent follicular orifice, and find it to be a particle of dust 
accidentally lodged in the depression. It is not, as in comedo, free 
pigment that has found its way to the surface ; nor, as in ringworm, is 



TINEA TRICHOPHYTINA. 751 

it the stump of a hair on a level with the surface of the scalp. In favus 
the cup-shaped crust will sooner or later betray the character of the 
disease to the naked eye. 

Confirmatory evidence as to the nature of the disease will often be 
furnished by a careful search for the source from which it was derived ; 
and for obvious reasons this should always be attempted. Ringworm 
of the body occurring upon the individual patient affected with tinea 
tonsurans, or upon other members of the same household, and suspi- 
cious " mangy " patches upon horses, dogs, cats, rabbits, white mice, or 
other animals with which the child may have been in contact, should 
always receive attention. 

Treatment. — The indication for the relief of the disease is the de- 
struction of the parasite ; and there can be no question that this may be 
accomplished in some cases without having recourse to epilation. The 
parasiticides named in connection with ringworm of the body, if thor- 
oughly applied in simple cases, after clipping or shaving the hair and 
efficient scrubbing of the patch with spirit of green soap and water, 
will occasionally be followed by permanent relief. Prominent among 
these parasiticides may be named formalin (1 to 5 per cent, in aqueous 
solution), pyroligneous acid, sulphurous, acetic, salicylic, and boric acids, 
saturated solutions of sodium hyposulphite, acetum cantharidis, tincture 
of iodine ; Crocker's ointment containing thymol, 1 part to 4 ; Morris's 
solution of thymol in chloroform and olive-oil (see Tinea circinata) ; 
and ointments of boric acid and sulphur, of each 1 drachm (4.) to the 
ounce (30.) of vaselin, and chrysarobin, the action of the latter being 
carefully limited to the patch of disease by the aid of a skull-cap. 

Epilation, however, is a valuable, and often an essential, method of 
treating the disease, and it may be practised as recommended when 
considering the treatment of favus. The scalp in each case should 
first be oiled, and be cleansed by the soap-shampoo, and after the epi- 
lation is performed an appropriate parasiticide should be employed. 
The calotte, made by spreading pitch-plaster upon leather or muslin, is 
a clumsy substitute for epilation in order to remove the hairs, but the 
sticks recommended by Bulkley may be employed, the formula for the 
preparation of which has already been given. In each case the epila- 
tion should remove a zone of sound hairs encircling the diseased patch, 
that the encroachments of the fungus may in every possible way be 
1 limited. It should not be forgotten, however, in the treatment of 
tinea tonsurans by both epilation and parasiticides that in chronic 
i cases these methods in the hands of the most expert have failed for 
consecutive months to relieve radically the disease ; that even the most 
inveterate cases, in the course of time and as adult years are reached, 
are spontaneously relieved without permanent alopecia ; and that no 
remedy or procedure is ever justifiable which is capable of either pro- 
ducing follicular atrophy or an effect worse than that wrought by the 
disease itself. 

Coster's paste is popular among English practitioners, including 
Stowers, Fox, Liveing, and others. It contains 2 drachms (8.) of 
iodine in crystals, dissolved in oil of tar ; and is painted over the 
part at intervals of a few days. It is most useful in circumscribed 



752 PARASITIC AFFECTIONS. 

patches of the disease. Among other remedies employed, some of 
which have been described in connection with ringworm of the body, 
may be named mercuric chloride, ammonio-chloride, red oxide, oleate, 
and ointment of mercuric nitrate ; epispastics ; pure carbolic acid 
and carbolated glycerin ; sulphur, chloroform, ether, tar in ointment, 
and Wilkinson salve. 

To be effectual the treatment pursued must be persistent and thor- 
ough, and always be accompanied by frequent washings and soapings 
of the affected part. 

The induction of suppuration in the hair-follicles (or a species of 
artificial kerion), by the aid of electrolysis and croton-oil liniment, has 
been praised by Alder Smith and Wyndham Cottle, of London, and 
later, in a modified form, by Magee Finny, of Dublin. By the process 
of Finny, 100 parts of the oil are mixed with 50 each of cocoa-butter 
and white wax. Sticks are made of this compound which can thor- 
oughly be rubbed into the part affected. By both methods it is claimed 
that no pain is produced, nor is permanent alopecia the result. A so- 
lution of salicylic acid is applied after each treatment, and a subsequent 
poultice may also be needed. In these cases the parasite is destroyed 
presumably by the suppuration excited. As in the case of ringworm 
of the body, tinea tonsurans is not remediable by internal treatment. 
Such internal medication, however, may be indicated by the systemic 
condition of young patients, and should be in each instance such as 
that condition suggests. 1 

Prognosis. — The prognosis in every judiciously treated case of 
tinea tonsurans is favorable, since all patients ultimately recover 
from the disease per se. Under the best treatment many cases prove 
extraordinarily tedious, month after month passing without marked 
improvement. The disease, however, in a large proportion of cases 
among children surrounded by proper hygienic conditions, especially 
as regards cleanliness, is readily relieved. 

Tinea Keeion (Kerion Celsi, from xypiov, a honey-comb). — 
The occurrence of active and usually circumscribed inflammation in 
a portion of the scalp affected with ringworm is at times followed by 
certain peculiar features. This complication of ringworm was recog- 
nized early in the history of medicine by Celsus, whose name has 
since been associated with its lesions. Tilbury Fox, in 1866, was first 
to recognize its identity with tinea tonsurans ; and it has since been 
the subject of a number of papers by Tanturri, Maiocchi, Schilling, 
Barduzzi, Auspitz, and Wilson. In the United States Atkinson 2 has 
made it the subject of a memoir. 

The symptoms . are the occurrence of acute inflammation, usually 
circumscribed, though occasionally diffuse, in a portion of the scalp, 
where a tumor forms which may project a considerable height above 
the general level. In time the appearance presented is suggestive of 
anthrax benigna, since from the tumid orifices of numerous distended 
follicles a viscid, semitransparent, puriform fluid exudes. The latter 

1 See also paragraphs on page 758. 

2 Arch, of Derm., January, 1881, vol. vii., No. 1. 



TINEA TRICHOPHYTINA. 753 

is characteristic. The hairs loosen and fall. When the view of 
the lesion is not obscured by the pilary growth it appears as a 
flattened hen's-egg- to turkey's-egg-sized, boggy, semiglobular tumor, 
its surface congested, reddened, glazed, and often exhibiting other evi- 
dences of inflammation, with split-pea-sized, pustule-like lesions dis- 
tributed over its surface, or, when these have ruptured, exhibiting the 
gaping apertures described above, from which a gummy secretion is 
poured in varying quantities. Modification of this condition occurs, 
such as the production of a true subcutaneous abscess with fistulous 
sinuses. The sensations awakened are usually painful ; the course of 
the disease is chronic. It may begin with the usual symptoms of ring- 
worm of the head, though often there is no history of the latter. The 
complication is a rare one. 

The parasite may and may not be found in patches of kerion, 
according to the acuity of the present or the precedent inflammatory 
process. If the latter be of high grade, and suppuration result, the 
fungus is destroyed, a result the attainment of which has been at- 
tempted in the production of " artificial kerion " by means of croton- 
oil for the relief of tinea tonsurans. In the earlier stages repre- 
sented by deep-seated follicular inflammation, with pustulation of the 
hair-shafts, the latter may be seen microscopically to be invaded with 
spores. 

The treatment is either by the milder parasiticides or by the methods 
proper for the relief of ordinary phlegmonous inflammation of the scalp, 
according to the stage of the kerion. The pus-cocci present in some 
of these cases require boric-acid lotions and bichloride washes. 

Tinea Sycosis; Hyphogenous Sycosis. 

(Tinea Barbae, Sycosis Parasitica, Mentagra Parasitica, 
Ringworm of the Beard, " Barbers' Itch." Ger., Para- 
sitare Bartfinne; Fr., Trichophytie Sycosique.) 

Symptoms. — The disease is best studied at its onset in the beard of 
a blonde subject with relatively fine, downy hairs, where are presented 
the typical features of tinea circinata, ringworm of the body. One or 
several, reddish, pea- to small-coin-sized rings become visible, with pin- 
point-sized vesicles, branny scales, and often, indeed, no other lesion 
save a hypergernic, scarcely elevated margin at the periphery. The 
hairs over the patch may be fragile, and clusters of pilary filaments here 
and there betray evidences of change. AVith proper treatment the dis- 
order may not progress beyond this point. 

In some cases the very slight degree of itching awakened by the 
process just described may be intensified, and large plaques form, a 
portion of which may extend from the region of the beard over the 
face and neck, or viae versa. When fully developed a phlegmonous 
disorder is produced which bears some analogy to the kerion just de- 
scribed, and which may so actively progress that it is first seen in 
typical development. The skin is congested and reddened, with sub- 
epidermic (or debris of ruptured) pustules at the orifice of the pilary 
follicles, and is studded irregularly with firm, pea- to nut-sized papules 

48 



754 PARASITIC AFFECTIONS. 

and tubercles. The tubercles are usually aggregated in masses or lumps 
which involve the skin and subcutaneous tissue, and they are firm, 
often tender and painful, rarely boggy and furuncular. When pierced 
they give exit to a characteristic, muciform, gluey, yellowish, and sticky 
fluid, puriform yet differing from pure pus, that rapidly dries into 
crusts. These composite lesions are usually circumscribed in a given 
area of involvement, very rarely covering the region of the beard in 
symmetrical disposition, more often limited to one cheek or to the 
cheek and chin. 

The hairs in the invaded region are involved as in ringworm of the 
scalp. These filaments break near the surface of the integument, leav- 
ing ragged stumps ; or they spontaneously fall after being loosened in 
their follicles. The ease with which they may be epilated is one of the 
most characteristic features of the disease ; they are slipped out of their 
follicles as readily as if they had been oiled ; or, as Anderson writes, 
" as easily as a pin can be pulled out of a pin-cushion. " They are then 
often whitish because enveloped in the fungus producing the disease. 
In either event the resulting gradual thinning or removal of the hairs 
renders the disease of the surface more conspicuous and deforming. At 
the edge of a patch thus exposed, deformed, lustreless, contorted, flat- 
tened, twisted, or split hairs may be found. Occasionally the features 
of the patch are changed in consequence of the unusual degree of sup- • 
puration excited. In this case the pustules burst and their contents 
concrete into dry crusts about the stumps of shafts of surviving hairs, 
from which circumstance the disease has received its name (sycosis, 
auxov, a fig). Rarely, a conglomerate crust covers the entire region 
with an excoriated, inflamed, and secreting surface beneath. 

Formidable cases of tinea sycosis have occurred in the persons of 
farmers, where the disease was long untreated and unrecognized. 
Some severe types of the disease have been produced after shearing 
sheep having diseased pelts. In these cases the cheeks, lips, and chin 
are the seat of nut- to fist-sized and larger cutaneous and subcutaneous, 
soft, boggy, and pus-filled tumors, accompanied by excessive soreness 
of the entire throat and neck, the hair falling from the follicles in large 
masses, and as if lubricated to facilitate their escape. 

Etiology. — The disease is always produced by the trichophyton. 1 
White, of Boston, has called special attention to the frequency of its 
origin in the barber-shop, a fact which common experience verifies. It 
is usually the irregular visitor to these establishments who is first to 
supply the germs of the disease. No individual proprietorship in cup, 
soap, brushes, and razor can secure against the danger of infection the 
person whose razor is drawn over a common strop, whose cheek is 
handled by unwashed fingers which have recently been passed over an 
infected face, or whose beard is combed, brushed, or rubbed with the 
implements and towels in common use at these establishments. The 
remedy is twofold : first, the full beard should be worn without shav- 
ing, as it is rare to find bearded patients of this class affected with tinea 
sycosis ; second, where the whole or any part of the beard is to 
be removed every adult male should shave himself. The physician 
1 See introductory paragraph on Ringworm. 



TINEA TRICHOPHYTINA. 



755 



should, in this connection, for medico-legal reasons be upon his guard 
against hastily deciding both as to the nature of the disease of his 
patient and the source from which it was derived. Of the first, he can 
become certain by his microscopical investigations ; of the second, he 
can only be sure by obtaining possession of facts far beyond the reach 
of the average practitioner. A medical gentleman once sent for exami- 
nation some hairs from the beard of a male patient affected with tinea 
sycosis. Before receiving a report confirming the diagnosis this phy- 
sician was sued by the barber in whose establishment the disease had 
been probably acquired, on the ground of libel. 

It is difficult to determine the frequency of the disease from sta- 
tistics. The affection is certainly relatively rare, yet more common 
than is often supposed to be the case. It is of somewhat irregular 
occurrence, months often passing without a case coming under obser- 
vation, after which several may be noted in rapid succession. 

Fig. 91. 




Filaments and spores of the trichophyton from the beard of a patient affected with tinea sycosis. 



The disease, being contagious, is one affecting men in all stations 
of life, and these usually at a period rather under than over the fortieth 
year. More men with light hair and eyes, and light-brown, reddish, 
or sandy beard are affected than those having darker shades of hair 
and eyes. Morris has called attention to the fact that tinea tonsurans 1 
occurs more frequently in blonde than in brunette subjects. 

Pathology. — The disease is essentially a follicular and perifollicular 
inflammation induced by the irritative effects of the fungus, precisely 
as in the case of tinea tonsurans. The difference between the clinical 
aspects of the two diseases may be explained in part by the habitual 
covering of the scalp with caps and hats while the face is left exposed ; 
and by the occurrence of tinea sycosis in adult years, while tinea ton- 

1 Lancet, 1881, pp. 164 and 241. 



756 PARASITIC AFFECTIONS. 

surans is predominantly a disease of childhood. As a result of the 
induced inflammation, vesicles, pustules, papules, and tubercles are 
formed, while the perifollicular inflammation may invade all portions 
of the skin and subcutaneous tissues, gluing together the plastic nod- 
ules formed about the individual hair-sacs into the lumpy masses char- 
acteristic of the disease. The invasion of the hair-follicles and hairs 
by the fungus is accomplished as in the case of ringworm of the scalp. 
Under the microscope spores and mycelium are visible, the forms pre- 
ponderating at the time when the disease first comes under observation, 
but probably preceded in most cases by abundance of thread-like forms. 
The identity of the disease with some forms of ringworm of the body 
and scalp does not, however, rest merely upon microscopical observa- 
tion, but is demonstrable by established clinical facts. Not only may 
ringworm be seen to spread from the face to the beard, but tinea ton- 
surans and tinea circinata may also transmit tinea sycosis, and the 
reverse. A physician had ringworm of the bearded chin and cheek 
derived from the face of a child under his care. He subsequently 
gave tinea circinata to his wife, who suffered on the face and shoulder, 
and she, in turn, communicated tinea tonsurans to her daughter. 1 

Diagnosis. — The distinction between coccogenous and hyphogenous 
sycosis is of chief importance in this connection ; and, necessarily, the 
microscope must be employed to settle the question definitely. The 
diseases, however, differ in their clinical features. The coccogenous 
form always fails to exhibit the nodules, tubercles, and composite cuta- 
neous and subcutaneous agglutinations of the disease produced by the 
fungus. The process in the former is more superficial, and it exhibits 
to the eye a more vivid redness as a result of the cutaneous hyperemia. 
Owing to the same cause, the frequent pus-containing lesions are de- 
veloped and elevated above the general level of the integument ; they 
are less commonly subepidermic crypts filled with characteristic mucoid 
puriform contents. The region of the bearded upper lip, so often 
involved in cases of nasal catarrh, is often spared by the tri- 
chophyton. When this parasite is present the hairs are characteris- 
tically loosened, distorted, and otherwise changed. This condition 
is not seen in the coccogenous disease ; exception, however, in this 
particular is to be noted in some long-standing cases of the latter. 
When the affection has persisted for many years (and one may often 
see patients thus affected) the thinned and starved condition of the 
pilary growth is a striking symptom, the scanty lustreless hairs 
often scarcely sufficing to conceal the deforming redness and pustula- 
tion of the surface from which they spring. The diffuse symmetrical 
affection of the hairy face, extending over both cheeks and chin, is 
more frequently connected with the presence of pus-cocci. Lastly, the 
hyphogenous, as a rule, is less painful and tender than the other form 
of sycosis, and, furthermore, is, without question of rarer occurrence. 

With respect to syphilis, it is to be noted that the papular or the 
pustular syphiloderm developed in the region of the beard is, almost 
without exception, to be discovered in other parts of the body, especi- 
ally the scalp. Ringworm of the scalp and the beard existing at the 
1 See introductory paragraphs on Ringworm. 



TINEA TRICHOPHYTINA. 757 

same time in one individual is rare. In syphilis there is usually an 
offensive odor to the abundant crusts ; shallow ulcers are also prone 
to form beneath the pustules ; and there is often a history of infection 
or a hint of the nature of the disease in its polymorphic character. 

Eczema of the bearded region may extend to or from other portions 
of the face, as in a case in which it sweeps -from the ear above. The 
presence of a stalactitic crust depending from the lobe of the ear of 
an affected side would at once furnish a clue to the nature of the 
disease in the beard. In eczema the interfollicular region is invaded, 
not deeply, as in tinea, but superficially, as in coccogenous sycosis. 
The itching is severe ; the hairs are not involved ; the infiltration is 
diffuse ; the outline is indeterminate ; and a halo of redness spreads 
from the affected part to the non-hairy surface in the vicinity. 

Treatment. — The treatment of tinea sycosis is generally conducted 
as in tinea tonsurans. It is customary to begin by anointing the 
affected surface with an oily or fatty substance, and to follow this with 
a shampoo of soap and warm water for the removal of crusts, after 
which shaving and epilation are practised on alternate days ; and para- 
siticides employed locally. For softening the crusts the spray of an 
atomizer may be used. 

Epilation of the male beard is often essential for removal of the 
disease, but the results of the treatment suggested below in the end 
may be satisfactory. 

The patient for two successive days keeps the affected part macerated 
with almond- or olive-oil. On the evening of the third day the sham- 
poo with soap is employed, and the skin is washed free from crusts and 
scales. The part is then cleanly shaved. This operation is at first 
painful, but gradually becomes less distressing. After shaving, the 
affected surface is bathed for ten minutes with borated water as hot as 
can be tolerated, by which means the inflammatory condition of the 
perifollicular tissues is, in a brief time, considerably reduced. While 
the bathing is in progress all subepidermic pustules or points where a 
mucoid fluid is coming to the surface are opened w T ith a fine aseptic 
needle. A solution of sodium hyposulphite is then sponged freely 
over the affected surface for several minutes and allowed to dry ; 
this solution may contain 1 drachm (4.) to the ounce (30.), or even 
more. After a thorough and final washing with hot water the tender 
skin is carefully dried and gently smeared with a sulphur ointment 
containing 1 to 2 drachms of sulphur (4.-8.) to the ounce (30.) of 
vaselin, often with the addition of from J to J (0.016-0.033) grain of 
mercuric sulphide. The patient then retires to bed. In the morning 
the unguent is washed off with soap and water, the sodium-solution 
is reapplied, and a borated or a salicylated powder is thoroughly dusted 
and kept over the part during the day. In the evening the shaving 
may be repeated or not, according to the vigor with which the beard 
is reproduced, but on the second day shaving is imperative. As soon 
as the pustulation ceases and the tubercles have manifestly diminished 
in size the ointment at night is superseded by the use, at that time 
also, of the dusting-powder. Whether the shaving is practised nightly 
or on alternate nights, ablution with very hot water and with solution 



758 PARASITIC AFFECTIONS. 

of sodium hyposulphite is continued nightly until the inflammation 
excited by the fungus is practically limited to the follicles that are 
invaded. The dusting-powder is to be thoroughly and constantly 
employed after the ointment is discontinued. With care and patience 
these measures may save many patients the annoyance of epilation ; 
and they should be continued for several weeks after apparent relief 
of the disease. 

The treatment may be varied to suit the needs of individual cases. 
Kaposi highly recommends, for example, 1 per cent, solutions of cor- 
rosive sublimate locally ; and the other parasiticides considered here- 
tofore in connection with the treatment of ringworm may serve also a 
good purpose. In some cases an ointment of thymol may be used with 
manifest advantage ; in others, a substitute may be found in Morris's 
solution of the same in chloroform and oil (the formula for this has 
already been given). In still other cases spirit of green soap with 
sulphur, finely powdered sulphur, boric, acetic, and carbolic acids, or 
other topical applications of recognized value may be employed. 

When resort is had to epilation, and this is essential in all severe 
cases, the hairs should be thoroughly removed from their follicles over 
every lumpy nodule, and even over every suspicious patch covered 
with scales. A zone should be cleared about each such papule. The 
results are prompt and in the highest degree satisfactory. 

Prognosis. — This disease is always remedied sooner or later, though 
it is at times tedious in its progress and characterized by relapses. 

Precautions to be Observed in the General Management of 
Tinea Favosa and Tinea Trichophytina. — The physician consulted 
in the case of a patient affected with either of the diseases thus far 
considered as resulting from the presence of a vegetable parasite should 
bear in mind that they are the most contagious of their class. He may 
not only himself suffer from the disease which he is attempting to 
relieve in another, but may also convey it to others, or be consulted 
by others of his patient's family actually infected during the course of 
the treatment pursued. 

Generally, it may be said that the hands of the physician should 
carefully be washed after each manipulation of the part, and preferably 
with a weak disinfecting solution. In the case of children the lining 
of all caps, hoods, and other coverings of the head should be removed 
and destroyed by burning ; and fresh linings made of tissue-paper re- 
newed daily ; while paper-caps of the same or of similar material should 
be worn when indoors. Brushes, combs, towels, and articles of cloth- 
ing should never be used in common by two or more individuals. 
When practicable, infected individuals should occupy separate beds ; 
and the bed-covering, clothing, toilet-apparatus, and dressing or other 
materials which have been in contact with a diseased surface should be 
immersed in boiling water before they are again employed for any use 
in common. Thin recommends covering every diseased patch, after 
the treatment appropriate to itself, with an adhesive and impermeable 
dressing, for the sake, not of the patient, but of those with whom the 
latter may be brought in contact ; and the suggestion is both wise and 



TINEA IMBRICATA. 759 

practicable. A man infected with ringworm of the beard in a barber- 
shop which he has visited but once, will often, when directed by his 
physician to shave, resort to some other establishment, where he is well 
known, and where he has more confidence in the cleanliness of the 
operators. In this way he often thoughtlessly spreads the disease of 
which he is the victim. It is well to send patients who cannot shave 
themselves to a particular barber, who, being instructed in the manner 
of shaving so as to insure immunity, generally fails to spread the 
disease in any case. 

TINEA IMBRICATA. 

(Tokelau Ringworm, Burmese Ringworm, Bowditch-island 
Ringworm, Lafa Tokelau, La Peta, Cascadoe, Gune, 
Herpes Desquamans. Fr., Herpes Tonsurans Desqua- 

MATIF.) 

This disorder was first described in 1844 by Fox, and has since 
been studied by Turner, Manson, MacGregor, and Roux. One of the 
best clinical descriptions is given by Crocker. 

Symptoms. — The disease is first declared, after artificial inoculation, 
by a period of delay (" incubation ") lasting about nine days, after 
which minute reddish points appear, arranged for the most part in 
semicircles, the former rapidly developing into papules producing an 
intolerable pruritus. The growth thenceforward is reported to be at 
the rate of from five to ten millimetres each week. In a brief time 
lamellae of epidermis are detached, their free border being directed to 
the centre of the circular disk, the patch or patches when fully de- 
veloped being represented by concentric rings, about five millimetres 
apart, suggesting a resemblance to " watered silk." The scales may be 
as large square as half a centimetre, with curling edges Avhich later 
become horny and much darker in color. It is said that the hand 
passed over such patches from the circumference to the centre recog- 
nizes a smoothness of the surface, but when the motion is reversed, 
from centre to periphery, the scales are raised and resist the fingers. 
The appearance of the older patches suggests a skin covered with 
clay. The process of production of the concentric rings is reported 
to be, first, by the elevation of a central point of the epidermis and 
the formation there by the fungus of a brownish mass ; then by sep- 
aration of the epidermis at the central point, with persistence for a 
time of attachments at the border ; then by liberation of the attached 
edge by friction or otherwise ; and finally by exposure of the corium. 
Just beyond this line a brownish rim declares the line of advance of 
the fungus beneath the epidermis. When the ring thus formed has 
attained a diameter of about five millimetres, a brown point again 
appears centrally, and there is a repetition of the process originally 
observed in the primary ring. 

All portions of the body may be affected ; but the scalp and face 
seem usually to be spared ; when the hairy parts (scalp, pubes, axillae) 
are involved the disease spares the follicles, and its management is 
thus declared to be correspondingly facile. Though the hairs them- 



760 PARASITIC AFFECTIONS. 

selves are not invaded, they are said to fall when the disease extends 
over the hairy regions of the body. When the disease spontaneously 
disappears from any portion of the integument there are left persistent, 
deep-colored rings or circles where the scaling originally occurred. 

Etiology. — The disease is always produced by contagion ; it occurs 
at all ages and in both sexes, especially in children ; and is chiefly 
encountered in tropical climates. 

Pathology. — According to Koniger (who was not a dermatologist) 
and Manson, the disease is produced by a special fungus, the tinea 
imbricata, which invades the epidermis without involving the hair- 
follicles, its oval or rectangular spores being more numerous than the 
mycelium, while the threads are long, straight, or gently curved. It 
is not yet determined that this parasite is not a development of the, 
trichophyton peculiar to certain tropical regions ; but Manson's state- 
ment, that inoculation of the same individual with both tinea imbricata 
and tinea trichophytina produces each disease separately, seems toler- 
ably conclusive on this point. 

The Diagnosis from "Giant Ringworm," "Boatman's Ringworm," 
" Dhabie's Itch," " Majee's Dad " — forms of trichophyton as it occurs 
in luxuriant vegetation upon the smooth portions of the body in 
tropical countries — is readily made. In these forms of ringworm the 
central area clears, while in tinea imbricata the central part of the 
patch is made up of concentric rings. 

Treatment. — The scales are readily removed with soap and water 
or by alkaline baths, and chrysarobin, pyrogallol, or iodine ointment is 
well rubbed into the part. In some cases strong lotions are employed 
of the same chemical constitution. 

The Prognosis is favorable. 






TINEA VERSICOLOR. 

(Pityriasis Versicolor, Dermatomycosis Furfuracea, Mycosis 
Microsporia, Chloasma. Ger., Kleinenflechte.) 

Symptoms. — The eruption in this disorder occurs in the form of 
few or of many, irregular, roundish, circumscribed or reticulated 
macules, pinhead- to small-coin-sized, rarely occupying an area the 
size of the palm or larger. In color it varies from the most delicate 
buff or fawn shade to a reddish, deep-brown, and even blackish hue. 
The surface of each lesion, when closely inspected, is usually seen to 
be covered with furfuraceous scales. If the scales are not visible, 
slight erasion with the finger-nail or the curette will demonstrate the 
fact that the superficial layers of the stratum corneum are, in the site 
of each lesion, readily separable from the tissues beneath. The eruption 
is most common upon the anterior surface of the thorax ; but it is also 
displayed upon the neck, the dorsum, the abdomen, and the other 
regions of the trunk, and the flexor aspects of the upper extremities 
(the hands only excepted). It is rarely seen upon the lower extremi- 
ties ; still more rarely on the face ; never on the hands and feet. The 
eruption is either unproductive of sensation or is accompanied by a 
mild pruritus. Patients usually declare that after profuse sweating, 



TINEA VERSICOLOR. 761 

bathing in warm water, or brisk friction of the surface minute epi- 
dermal rolls separate from the affected area. The disease may linger 
for years upon the surface of the body.. It has a special tendency in 
susceptible individuals to recur after removal. 

The eruption is occasionally encountered in extreme development. 
In a young married woman who had been the subject of the disease for 
many years the entire trunk, the axillse, the groins, the upper portion 
of the thighs, the neck to the level of the high collar worn, and the 
upper extremities to the wrists, were encased in a uniform sheet or 
cuirass of chocolate-tinted epidermis in a condition of exfoliation in 
finger-nail-sized lamellated flakes. Even in these extreme cases the 
tendency of the disease to avoid surfaces exposed to the light is dis- 
tinctly manifested. Unna l describes an anomalous feature of the dis- 
ease, in which the maculations occur in annular form with a clearing 
centre. Rarely, also, a very few irregularly distributed macules may 
be seen as the sole evidences of the existence of the parasite. Thus, a 
patient may exhibit a small-coin-sized patch on the surface of the chest, 
another on the shoulder, and possibly a third over the deltoid region 
of one arm. These are generally cases partially relieved of a more 
diffuse eruption. More commonly the slightest manifestation of the 
malady is an irregular, vertically arranged, somewhat narrow band of 
lesions immediately over the sternum, and visible beneath the hairs of 
that region in the adult male, or upon the intermammary sulcus of 
women. The face, hands, palms, soles, hairs, hair-follicles, and nails 
are usually exempt. 

Etiology. — The disease is produced by a vegetable mould, discov- 
ered in 1846 by Eichstedt, to which Robin gave the name Microsporon 
furfur. In capabilities for contagion it is far inferior to the vegetable 
parasites already described, and it illustrates well a point to which at- 
tention already has been directed, viz., that these fungi flourish only 
in soils suitable for their germination and fructification. Members of 
one family are said to communicate the disease occasionally, the one 
to the other ; and Lancereaux 2 reports that in this way he accidentally 
infected himself from scales collected for examination from a patient 
in hospital, and afterward unwittingly transmitted the affection to his 
wife. The disease occurs in both sexes, rarely before puberty and after 
middle life, and in persons of every social condition, irrespective of 
personal cleanliness. It is exceedingly common, more so, indeed, than 
statistics are capable of demonstrating, inasmuch as hundreds who are 
annually annoyed by it never seek professional advice. In physical 
examinations made with a view to the enlistment of men for military 
service, as also of government pensioners, the disease is often recog- 
nized upon the persons of those who pay no attention to its pres- 
ence. Being concealed by the clothing and unproductive of much dis- 
comfort, many subjects of tinea versicolor endure its presence with 
complacency. 

By some it has been supposed that the fungus selects the chest of 
the phthisical as its habitat, a supposition doubtless based upon the 

1 Vierteljahr. f. Derm. u. Syph., 1880, Nos. 2 and 3. 

2 Traite" d'Anatoraie pathol., xi., p. 265. Paris, 1875. 



762 



PARASITIC AFFECTIONS. 



fact that tuberculous men and women, more than all others, expose 
the chest to the view of medical men in order to permit of its auscul- 
tation and percussion. 

Pathology. — The Microsporon Furfur (Fig. 92) is readily recog- 
nized with the aid of the microscope, as it exists in luxurious profusion 
upon every affected surface. The scales may be scraped from the skin, 
and at once be examined, when innumerable clustered spores and short 
threads become visible ; the former highly refractive and resembling in 
their circular and oval contours droplets of oil. Their aggregation in 
clusters is distinctive of this among the other forms of cryptogamic 
vegetation. They measure 0.0023 to 0.0084 mm., while the hypha? 
vary in diameter from 0.0015 to 0.0038 mm. (Duhring). Among the 
latter, sporophores are distinguishable, with contained conidia and 

Fig. 92. 







Microsporon furfur. (After Kaposi.) 



terminal elements emerging at one extremity or the other of the spore- 
case. Both elements are more readily stained by eosin and methyl- 
violet than those of the trichophyton or of favus. 

One of the strongest arguments against the claim for the identity 
of all the vegetable parasites is furnished by the history of this inter- 
esting mould. It never by any possibility invades the hairs or the 
hair-follicles, though it may be seen flourishing at the orifice of a fol- 
licular duct, and even beneath a vigorous pilary growth upon the chest 
of a male subject. It avoids light and air ; and singularly refuses to 
encroach even upon certain covered portions of the body, preferring, in 
its extreme development, to linger unobtrusively at the neck near the 
verge of the collar. 

Diagnosis. — In this disease, as in all parasitic affections of vege- 



TINEA VERSICOLOR. 763 

table origin, the microscope may be required to decide the diagnosis 
in any case in which doubt arises. In its simpler manifestations the 
recognition of the affection is readily assured. The location of the 
eruption, its irregular reticulations, its characteristic yellowish or fawn- 
tinted shades of color due to the nature of the fungus, and the exfolia- 
tion of the epidermis which it excites by its superficial penetration of 
the outer layer of the stratum corneum, producing thus a mealy, branny, 
flaky, or roll-like exuvium, are all significant. None of the chloas- 
mata due to pigment-changes in the skin, however much they may 
resemble tinea versicolor in color, share with it this peculiarity of des- 
quamation. Chloasma may involve, moreover, the face ; tinea versi- 
color almost never. Vitiligo occurs upon the scalp ; tinea versicolor 
very rarely. The macular syphiloderm may be mistaken for the dis- 
ease under consideration, but, when developed to such an extent as to 
rival tinea versicolor in its diffuseness, the syphiloderm will creep out 
over the face, the hands, and the feet, and will be accompanied by 
adenopathy, alopecia, mucous patches, palatine hyperemia, or will fur- 
nish evidence of a polymorphic tendency. Often, indeed, with such 
an eruption, the survival of the initial sclerosis will at once betray the 
nature of the disease. These are important considerations, since in the 
mere matter of subjective sensation, color, shape, and size of lesion 
there may be marked resemblance between the two. Patients exhibit- 
ing the lesions of tinea versicolor may suffer from syphilis ; and many 
having the former disease, in consequence of a suspicious exposure 
believe they are infected with lues, and yet indeed are not. These 
incidents serve to illustrate the importance of making an accurate diag- 
nosis in every case of cutaneous disease. 

The most common error committed in this connection, however, is 
based upon the fancied resemblance in color between the patches of 
tinea versicolor and either the liver itself or the color-changes which 
disease of that viscus is capable of producing in the skin. The exist- 
ence of " liver-colored " spots in the skin is, hence, erroneously attrib- 
uted to hepatic disease. Few patients consult physicians for relief of 
this disorder who have not a belief in the internal origin of the disease. 

Treatment. — A single method of relieving tinea versicolor is recom- 
mended for the simple reason that it invariably is successful. It 
requires merely vigorous and intelligent cooperation on the part of 
the patient. A hot bath is taken, if possible, for three nights in suc- 
cession, and when the surface is well macerated in hot water the 
affected skin is scrubbed either with the cheap yellow soap of the 
shops, or with sapo viridis in substance or in tincture. When the 
disease is extensively developed this process is aided by friction with 
a flesh-brush or with a coarse towel. The skin is then washed clean 
with a surplus of hot water, and dried, after which the affected patch 
is first moistened with vinegar and water, or dilute acetic acid, and 
afterward well sponged with a solution of sodium hyposulphite, 1 
drachm (4.) to the ounce (30.) being usually sufficient. As a rule, 
the greater part of the eruption is removed with the third application. 
If there be recrudescence in isolated patches, as is often the case, or 
outlying areas which have withstood the parasiticide employed, they 



764 PARASITIC AFFECTIONS. 

should subsequently be attacked with a solution of mercuric chloride, 
1 to 2 grains (0.066-0.133) to the ounce (30.). Other measures, how- 
ever, are popular with physicians, and among them may be named the 
topical use of boric, carbolic, or sulphurous acid ; tincture of iodine ; 
sulphur in bath, ointment, or lotion ; calomel in ointment ; the alkalies 
in bath or lotion ; potassium sulphide in bath ; chrysarobin, pyrogallol, 
tar, Wilkinson's salve, and the other parasiticides employed in the 
treatment of ringworm of the body. The inner clothing should not be 
worn after treatment until it has been immersed in boiling- water. 
The following formula is also recommended : 

R 



Hydrarg. chlorid. corros., 
Saponis viridis, 
Spts. vin. rectif., 
01. lavandul., 


Rj; 

f3j; 


l 
60 
120 

4 


33 
M. 






1 Anderson 



Prognosis. — The disease can readily be relieved by simple treatment. 
Relapses often occur, and require to be radically treated. Untreated, 
the disease may continue for years without the slightest impairment of 
the general health. It is probable that when untreated the parasite 
undergoes spontaneous exfoliation in advanced years, a period when 
presumably the fungus fails to find in the epidermis the nutriment upon 
which it thrives. 

ERYTHRASMA. 

(Gr. epvdpdc, red.) 

Burckhardt first described this disorder in 1869, but it received its 
name in 1862 from von Baren sprung. It has since been studied and 
described by Balzer, Riehl, Koebner, Pick, and others. 

Symptoms. — The disease first appears in punctiform to palm-sized, 
roundish, definitely circumscribed maculations, presenting a sharp con- 
trast in color with that of the adjacent integument. This hue varies 
somewhat according to the location of the patches. The younger lesions 
may exhibit a vivid redness over the entire macules or over their borders 
only. The older lesions exhibit a yellowish or a brownish tinge. These 
colors are compounds of ordinary erythematous redness and yellowish 
or brownish discoloration of the horny layer of the epidermis. 

The macules are circular or rosette-shaped, or they display very irreg- 
ular outlines. They are not raised to any extent above, the general 
level of the skin, though the finger passed over the surface can recognize 
a slight elevation of the border, due to hyperemia, and subsequent 
moderate, flour-like furfuraceous desquamation, most conspicuous also 
at the periphery. Vesiculation and papulation do not occur. The 
colors recognized in different patches may be light reddish-brown, pale 
reddish-yellow, and light or dark orange. 

The eruption is most commonly encountered where apposed surfaces 
of the skin come in contact, as in the axilla?, the groins, the cleft of 
the anus, and the regions where the scrotum touches the thigh ; it 
occurs, however, in typical expression on both sides of the chest. The 
eruption spreads slowly and in serpiginous outline until the affected 



EBYTHBASMA. 



765 



surfaces are completely invaded. It is much more chronic in its course 
than the other dermato-mycoses, lasting for months and years without 
apparent change. 

Etiology. — Erythrasma is produced by the growth, in the superficial 
layers of the epidermis, of the fungus described below. Men are much 
more often affected than women ; children not at all. The youngest 
patient whose case is recorded was sixteen years old ; the oldest, 
fifty-five. 

Pathology. — The fungus termed Microsporon Mixtjttssimum 
(Fig. 93), to which the disease is attributed, is chiefly remarkable for the 
extraordinary delicacy and fineness of its threads and its very minute 
spores. The threads are either simple cylindrical bodies of variable 
size, or they may exhibit partition-septa ; they may divide dichotomously, 



Fig. 93. 




Microsporon minutissimum, from patches of erythrasma. 



and may terminate in hooked or knobbed expansions. They are inex- 
tricably interwoven when occurring in large masses. The largest 
transverse diameter is 0.6 p. ; in length the mycelium presents the 
greatest variation. Bacteria and heaps of zoogloea are visible among 
the scales. The granules are piled into irregular heaps, according to 
Burckhardt, and they give a dusty appearance to the epidermal cells 
on which they lie ; often the outline of these granules is indistinct. 
According to the same observer, the breadth of the hyphse is yjVo mm. ; 
and the length from y 1 ^ to ^J-^ mm. 

Pasquale de Michele 1 discovered the leptothrix in cases of supposed 
erythrasma ; and this is but another of the proofs that in all diseases 
of this class, as in so-called " eczema marginatum/' there are few in- 
stances in which a single mould-fungus develops on the body-surface. 

1 Annal. de Derm, et de Syph., 1891, p. 776. 



766 PARASITIC AFFECTIONS. 

The entire flora deriuatologica of Unna may be effective in more cases 
than is commonly believed. 

Diagnosis. — From all ordinary chloasmata and pigment-macules the 
spots of erythrasma are distinguishable by the ease with which the 
superficially embrowned epidermal layers are removed by erasion. 
Tinea versicolor is distinguished from erythrasma with greater difficulty ; 
but the latter occurs in different situations by preference, its patches are 
more vividly red, and the parasite, under the microscope, presents 
distinctive features. 

The Treatment is that of tinea versicolor ; and the Prognosis is 
favorable, subject to the disappointments arising from frequent relapses. 

LA PERLECHE. 

Under this title, Justin Lemaistre l describes a contagious disease 
observed by himself in more than three hundred children of Limoges. 
It is not rarely recognized in the skin-clinics of the Paris hospitals. 
The malady is characterized by dryness, smarting, cracking, and exco- 
riation of the lips, the epithelium of which becomes blanched, mace- 
rated, and readily detached. Hemorrhagic and painful fissures form 
in the direction of the commissural folds. Often plaques are visible, 
suggesting mucous patches. The disease lasts for from fifteen days to 
a month, with possible recurrence which may lead to a year's suffering. 

The disease is of parasitic origin, communicated by drinking from 
cups used by infected persons. Lemaistre attributes the disease to a 
streptococcus plicatilis which he has cultivated in Pasteur flasks. The 
microbes were originally found on the borders of epithelial cells of 
the lips of infected children. The parasite lives in the form of a 
micrococcus in stagnant water, wells, and springs. The disease is one 
of uncleanliness, and is readily prevented by appropriate hygiene. 

MYRINGOMYCOSIS. 

(Otomycosis.) 

The spores of aspergillus (niger, flavus, fumigatus), being conveye 
to the external ear, occasionally develop there, especially if they come 
in contact with fatty substances introduced for purposes of medication. 
There can then be recognized in the canal whitish masses, covered 
with grayish-white, yellowish, greenish, brownish, or blackish spots. 
In the normal ear this vegetation cannot flourish ; its occupancy of 
the canal is conditioned on a maceration of the epidermis due to some 
antecedent inflammatory or other affection. 

Examination of the debris removed from the ear reveals the inter- 
laced hyphse of the vegetation with spores and occasional flower-like 
masses which constitute the sporangium of the fruit-capsule of the 
aspergillus, this last containing the receptaculum and radiating sterig- 
mata bearing the conidia. Diffuse inflammation, otorrhcea, and eczema 
of the part may result. There is usually some deafness, with a sensa- 
tion of ringing in the ears, and at times a thin serous discharge from 

1 Le Progres raid., October, 1884. 




CARATES. 767 

the external auditory meatus. Lowenberg 1 recommends for the de- 
struction of the mould the injection of dilute alcohol into the canal and 
the subsequent insufflation of boric acid in powder. 

CARATES. 

(Pinta Disease, Mae de los Pintos, Spotted Sickness, Cute, 
Caeaate, Cativi, Quirica. Fr. y Cakates.) 

Under one or more of the titles given above has been described by 
Hirsch, Iryz, and others a group of maladies characterized by the pro- 
duction on the surface of the body of superficial areas of involvement 
ranging in hue from a yellowish-white to a dark chocolate color, vary- 
ing with different individuals and exhibiting varying shades upon one 
affected subject, having a tendency to peripheral extension over the 
face and extremities, and in general, except the palms and soles, upon 
regions exposed to the air, and due to a vegetable fungus developing 
in the superficial layers of the integument. 

The patches of the disease appear commonly over the exposed 
rather than over the protected body-surfaces, as, for example, over the 
cheeks, the nose, the forehead, and the temples, in circular or ovoid 
variously sized plaques having a yellowish or purplish or brownish 
shade of color. They are often intensely pruritic. 

Though displayed for the most part asymmetrically, these patches 
may cover the entire surface of the body and even invade the mucous 
membranes of the alimentary tract. When confluence occurs large 
areas of the skin may be involved, displaying then the usual features 
of hyperkeratinization, with pityriasic, occasionally larger and coarser 
scales, infiltration, occasional Assuring, and complete or partial color- 
change and loss of hair. In final evolution the symptoms are highly 
suggestive of other dermatoses, such as trichophytosis, favus, some of 
the forms of lupus, and erythematous eczema. There may be ulcer- 
ative complications. The disease occurs at all ages and in both sexes : 
is more common among the poor and the neglected ; is rare among the 
whites ; and may endure for years. 

Etiology and Pathology. — The effective parasite is of the asper- 
gillus family, fine filaments giving rise to hyphse which terminate in 
clubs surrounding chaplets of spores. Sterigmata encircle the sporu- 
lating elements. The color of the fungus varies according to the hues 
of the invaded integument. The fungus is found chiefly in the super- 
ficial layers of the epiderm, but may also in advanced cases be recog- 
nized in the rete. 

The Diagnosis is between macular leprosy, tinea versicolor, the sev- 
eral forms of leucoderma and vitiligo, and the varieties of ringworm, 
pityriasis rubra pilaris, and keratosis ; the recognition of the effective 
fungus being decisive. 

The Treatment is by parasiticides, the mercurials, sulphur, chry- 
sarobin, pyrogallol, and potassic permanganate. 

The Prognosis is favorable save in cases that prove refractory 
under treatment. 

1 Oaz. hebd. de Med. de Paris, 1880, 2me s6r., xvii., p. 579. 



768 PARASITIC AFFECTIONS. 

MYCETOMA. 

(Gr. pvK7jg } a fungus.) 

(Madura Foot, Fungus Foot of India, Podelcoma, Tubercular 
Disease of the Foot, Endemic Degeneration of the Bones 
of the Foot, Morbus Pedis Entophyticus, Ulcus Grave.) 

From the date of the earliest description of this disorder by Eyre 
in 1806 to a recent date Indian physicians chiefly contributed to the 
literature of this disease. Among them may be named Brett (1840), 
Jille (1842), Ballingall (1855), Vandyke Carter (1859), Berkeley 
and Biddie (1862), Hirsh (1863), Lewis and Cunningham (1875), and 
still more recently Layet, Liboroux, Bocarro, Bassini, Huntley, Sur- 
veyor, Boyce, Gemy, Vincent, and Kanthack. 

The disease chiefly occurs in India, but is reported to have been 
observed also in China, Africa, Syria, and, in isolated cases, in a few 
countries of Europe. 

The record of its first recognition on the American Continent is 
embodied in the apparently unsupported statements of Ruelle, 1 who 
reports that Collas observed one case at La Reunion ; Grail and 
Grand-Mourrel, each one case in Guiana ; and Layet one in Chili and 
another in Valparaiso. McQuestin 2 saw three cases affecting native 
Mexicans in the Civil Hospital of Hermosillo, and Kemper 3 reported 
a case which for some years w T as thought to be the first occurring in 
the United States, but a critical examination of the description of the 
acute symptoms presented by his patient raises doubt respecting the 
accuracy of the diagnosis. Charles T. Parkes reported that he had 
successfully operated upon a patient suffering from mycetoma in the 
city of Chicago. The disease had, however, been contracted in India. 

The first case certainly known to have originated in North America, 
in which no question exists as to the diagnosis, was reported by Adami 
and Kirkpatrick. 4 The subject was a French Canadian. Soon after 
the appearance of this report one of us in connection with Senn and 
Bishop published the record of an undoubted case of mycetoma 3 occur- 
ring in a native of Iowa who had never been outside of his native State 
before visiting the city of Chicago. The lesions of the disease, as 
exhibited in the foot removed from this patient, are depicted on the 
accompanying plate. Since then Pope and Lamb, 6 Wright, 7 and 
Arwine and Lamb 8 have published full reports of undoubted cases 
with demonstration of the fungus and its subsequent artificial culti- 
vation. This record of five cases of Madura foot in North America 
includes the history of four men and of one woman. 

1 Contribution a 1' etude du Mycetome, Bordeaux, 1893, p. 13 etseq. 

2 Pacific Med. and Surg. Jour., 1873, pp. 652-555. 

3 American Practitioner, 1876. 
* Trans. Assoc. Amer. Phys., 1895, vol. x., p. 92. 
5 "A Contribution to the Study of Mycetoma as it Occurs in America," Jour. Cutan 

and Gen.-Urin. Dis., January, 1896. 

6 N. Y. Med. Jour., 1896, vol. lxiv., p. 386. 

7 Trans. Assoc. Amer. Phys., 1898, vol. xiii., p. 471. 

8 Amer. Jour. Med. Sci., Oct., 1899, p. 393. 




r \-it\. i i-j ^wv v 







Fi 





%s 








C ABATES. 



769 



Symptomatology. — There are two varieties of mycetoma — the 
black, and the white, red, or ochroid. Some doubt exists as to whether 
all are produced by one fungus, seeing that no intermediate forms 
between the varieties thus distinguished have yet been recognized. The 
part principally affected in most of the Indian and in the American cases 
is the foot, and this chiefly of persons walking barefoot ; but the hand, 

Fig. 94. 




Osseous lesions in mycetoma. 



the shoulder, the knee, the scrotum, and other regions have been at- 
tacked. As distinguished from the lesions of actinomycosis, it is note- 
worthy that the regions of the jaw and the neck are usually spared. 

In a typical case the foot is involved by progressive spread of the 
disease from the site of a trifling traumatism which often at first heals, 
and is followed later by the development, near the site of the wound, of 

49 



770 PARASITIC AFFECTIONS. 

a button or nodule which both increases slowly in volume and is later 
surrounded by similar lesions. The progress of the disease is exceed- 
ingly chronic, as ten and many more years have not rarely been re- 
corded as required for its complete evolution. 

In fully developed cases, when the foot is involved, the organ is 
seen to be largely increased in volume, producing a bulging of the 
parts posterior to the digits over the dorsum above, and below over 
the plantar region, giving the sole a convex appearance. Over the 
tumid parts the skin is beset with numerous pea- to nut-sized iso- 
lated nodules, elevated to the extent of several millimetres above 
the general level, each pierced with a fistulous channel extending 
from without to the deeper structures. At times these fistulous tracts 
lead only to the soft parts and especially to muscular tissues ; at others 
the surface of the bone is reached and the osseous tissue is eroded by 
the growth of the parasite and the coccogenous infection which results 
from long exposure of the parts to the air. It is through these fistulous 
orifices that in different cases exit is given to a blackish fish-roe-like 
substance, or to a whitish material, or even still more rarely, as indi- 
cated above, to a reddish substance. 

In place of nodules or papules, the skin may be the seat of pustules, 
of vesicles, of bullae, or even of abscesses. When but relatively small 
organs of the body are invaded, such as a finger or a toe, it becomes 
clear that the tumefaction is not due chiefly to a hypertrophy either 
of the integument or the bones. 

Etiology. — The disease, though of more common occurrence in 
India than elsewhere, may develop in other lands. The relatively fre- 
quent involvement of men is probably due to the greater exposures of 
the bare feet in persons of that sex. The disease is produced by a 
vegetable parasite, which obtains access to the tissues, as far as is known, 
usually through, a traumatism. 

Pathology. — The effective parasite in Madura foot is the actino- 
myces Madurse (streptothrix Madurse of Vincent ; oospora Indica 
of Kanthack), a mycelium with branching threads, hyphse of some- 
what greater thickness, and ovoid spores measuring 1.5 by 2 p.. 
Two forms of granules have been recognized : the melanoid, or 
" black " variety, which are irregularly shaped and which coarsely 
resemble gunpowder ; and the ochroid, or " pale " variety, charac- 
terized by whitish or grayish-yellow bodies somewhat resembling 
fish-roe. The clinical symptoms of the two varieties are simi- 
lar. Hektoen * distinguishes the pale form of mycetoma by the title 
actinomycelial, and the black as the hyphomycelial, the character of the 
black organism having been demonstrated by the successful cultivation 
of the fungus in the case reported by Wright. Under the microscope 
the lobate-reniform masses constituting the " grains " are seen to be 
formed by a dense centrally placed mycelium with peripheral filaments 
which radiate uniformly from within outward, and which may or may 
not terminate in " clubs," these last being probably the resultant of the 
interplay of force between the outspreading fungus on the one hand and 
the resisting power of the tissues on the other. 

1 N. Y, Med. Jour., May 26, 1900. 



ACTINOMYCOSIS OF THE SKIN. 771 

In the three areas to be equally recognized on section of the 
"grains," the central exhibits delicate filamentous threads radially 
arranged ; the marginal zone longer, more distinct, and somewhat more 
slender threads ; while the radial zone, separated from the last by a 
narrow space, exhibits a few granular threads, but for the most part 
appears to be made up of a granular tissue, the mycelium of degener- 
ated hyphse surrounded by a reticulum. Outside of the fungous mass 
are closely packed leucocytes, new-formed vessels having walls infil- 
trated with proliferating cells, few or numerous giant-cells, and in 
many of the lymph-spaces adjacent to the fungi large numbers of 
amorphous granular masses, refractive and yellowish brown in color, 
which Carwell believes to be hemosideria. The bones when denuded 
of tissue are found to be honeycombed with finely carved seams, 
depressions, furrows, and pits, leaving delicate spicula of osseous tissue 
projecting between the excavations wrought by the growth of the para- 
site. It is possible to find, as Adami suggests in the study of his case, 
intrusive organisms, the result of exposure for so long a period of time 
of the deeper tissues to the atmosphere. Cultures are made in bouillon 
and potato-infusion showing a hyphomycete with loug branching threads 
and transverse septa. 

The fungus differs from that of actinomyces in that the former 
reacts indifferently to, while the rays of actinomyces are brilliantly 
colored by, acid fuchsin. 

Diagnosis. — The disease in all cases of long standing is readily 
recognized by the characteristic deformity it produces, by the escape of 
fish-roe-like particles in the black variety, and in others by the dis- 
charge of the elements of the fungus, w T hich can be determined by the 
microscope. The nodes or papules visible externally in all well-marked 
cases, each perforated with a sinus leading downward to the deeper 
structures, and the painlessness for the most part of the involved 
organ, are all characteristic. 

As distinguished from actinomycosis, it is well to remember that in 
mycetoma there is never involvement of the viscera ; the disease is 
exceedingly chronic ; all systemic symptoms are absent ; and the 
affection is common in countries where actinomycosis is practically 
unknown. 

Treatment. — The disease is radically treated by surgical ablation 
of the affected organ or by erasion of tissue. Even after evolution of 
the disease for years recovery in cases so treated is satisfactory. 

ACTINOMYCOSIS OF THE SKIN. 

(Gr. clktIq^ and ^k-VC, mushroom.) 

(" Lumpy-jaw/' Ger., Aktinomykose ; Fr. Actinomycose.) 

This disease was first recognized in 1887 as due to a parasite which 
Harz described, from its gross appearances, as the " ray-fungus," 
occurring in the jaws of cattle. It has since been recognized in man, 
and still later, by Majocchi, as of occurrence in the skin. 

Symptoms. — In actinomycosis this parasite usually effects entrance 
through a carious tooth, and the skin when implicated is, as a rule, 



772 PARASITIC AFFECTIONS. 

secondarily involved. Such skin-lesions are more often displayed I 
about the face and neck, more particularly the lateral surfaces of the 
neck beneath the jaw, where deep subcutaneous nodes, tumors, or 
swellings, often firm to the touch, livid in hue, thinning at one or at 
several points after involvement of the integument, finally burst, form- 
ing pustular tracts and giving exit to a serosanguineous or bloody and 
purulent fluid, containing yellowish masses in which the fungus may be 
recognized. The orifices of the sinus or sinuses after such discharge 
are usually beset with cutaneous and subcutaneous nodules and uneven 
lumps, some softened, others firm and indurated, usually reddish or 
purplish in hue, tender, painful, and often accompanied by pains else- 
where, particularly in mastication, in deglutition, and in certain move- 
ments of the head on the neck. 

The onset of the disease is insidious, and it is said to occupy 
months and even years. The nearer to complete evolution of the dis- 
ease the more rapid, as a rule, is the development of its symptoms. 
In exceptional cases the malady attacks the fingers, the hands, and 
other parts of the body. Rarely, secondary actinomycosis of the 
lymphatic glands occurs. Pringle reported a case in which large areas 
on the back, lumbar region, and hip were affected secondarily after 
involvement of deeper organs. 1 Lymphatic metastasis is, however!, 
rare, due, as is believed, to the large size of the fungus-granules as 
compared with the lumen mi the lymphatic vessels. 

Etiology. — As in mycetoma, more men than women are attacked as 
a result of special exposure ; a few of the affected have been occupied 
with cattle and horses ; others having carious teeth may have been 
infected by accidents of contact or in the operations of dentistry. 
Murphy, of Chicago, had a case of this disease in the person of a 
woman whose dog had died with a large swelling under the jaw. In 
most instances there have been submaxillary lesions and carious teeth. 
The general dispersion of the ray-fungi in the atmosphere, water, and 
upon the soil is held to explain in large measure the occurrence of the 
disease in man. Beards of barley, bits of stone, vegetable fragments, 
etc., have been found in actinomycotic lesions. 

Pathology. — Typical actinomycosis is produced by invasion of 
the human body by " typical pathogenic ray-fungi " (actinomyces), the 
organisms differing from the " atypical acid-proof ray-fungi/ 7 which in 
a few instances have produced disease both in man and animals sug- 
gestive of certain forms of tuberculosis. 

The " typical pathogenic organisms " form long branching threads 
with stellate radiations, from which the title actinomyces receives its 
name. The " atypical " forms are distinguished by the absence of 
spore-bearing hyphse and by their resemblance in polymorphous de- 
velopment to certain of the bacteria. 

The granules which form in human actinomycosis are yellowish or 
grayish clumps. When closely examined these are found to be a circlet 
of club-shaped masses radiating from a network of mycelial threads, 
the ends of which eventually undergo hyaline degeneration or gelatini- 
zation. The growth of the parasite in the tissues results in the forma- 

1 Medico-Chirurgical Transactions, vol. lxxviii. 



ACTINOMYCOSIS OF THE SKIN. 773 

tion of granulation-tissue which may undergo purulent disintegration ; 
and there may be extension of the process by hematogenous metamor- 
phosis, rarely by secondary actinomycosis of the lymphatic glands and 
vessels, by dissemination by phagocytes of mycelial fragments, and 
lastly by secondary mixed infections with the pyogenic micro-organisms. 

Diagnosis. — All supraclavicular and submaxillary lesions consti- 
tuted of dark-reddish tumors or swellings, subcutaneous in origin, 
should carefully be differentiated from actinomycosis. Scrofuloderma 
is to be recognized by the general condition of the patient (actinomy- 
cosis may occur in vigorous young adults) ; by the absence of pro- 
nounced gumma and lymphoma (" gomme scrofuleuse ") ; and by failure 
of recognition of the parasite, which is not easy of detection. The 
occupation of the subject of the disease (as a farrier, stable-boy, or 
drover) may furnish a clue to the origin of some cases. Care should 
always be taken, in making a diagnosis, to exclude cases of swellings 
discharging pus, practically limited to the skin immediately over the 
lower jaw, with sinuses leading to the bone beneath, in which the dis- 
order is exclusively due to a carious fang of one of the lower central or 
canine teeth. All these may be relieved by extraction of the offending 
tooth. 

The Treatment has been until recently by surgical procedures, era- 
sion, antisepsis by mercuric chloride, boric acid, and dressings with anti- 
septic gauze. Gautier has employed with success an electro-chemical 
method of treatment, by the use of platinum needles and injections of a 
10 per cent, potassium iodide solution. Two needles are inserted, one 
connected with each pole of the battery, and a current of fifty milli- 
amperes is passed ; a few drops of the iodine solution are injected during 
the flow of the electricity, the patient being anaesthetized. Before 
attempting surgical measures potassium iodide given internally should 
be tried, since it has proved successful in a number of cases. Pringle's 
case, mentioned above, improved under the iodide, though the patient 
was never able to take the remedy in large doses, and eventually died 
from amyloid disease. Morris reported a case which under the in- 
fluence of the iodide lost its characteristics and the fungus gradually 
disappeared. Other cases are reported in which recovery followed 
administration of the iodide. 

Prognosis.— It was held until lately that the prognosis was favor- 
able only in case of thorough and prompt removal of all diseased tissue. 
In other cases a fatal result was anticipated. 

Schlange, however, at the Congress of German Surgeons held in 
1890, called attention to the fact that of nearly two hundred patients 
under his observation (over one-half traced since 1886), forty were com- 
pletely cured for more than two years ; and in eighty the disease re- 
mained limited to the head and neck. After thirteen years of involve- 
ment one patient at the date of the report was alive. All extensive 
operations for relief of the malady are now abandoned. Potassium 
iodide is effective in some cases, and is worthy of a trial in all. Even 
actinomycosis of the lungs and viscera is susceptible of spontaneous 
recovery. Cases apparently hopeless have recovered in five and six 
years. Intestinal complications are grave. 



774 PARASITIC AFFECTIONS. 

BLASTOMYCOSIS OF THE SKIN IN MAN. 

(Blastomycetic Dermatitis, Saccharomycosis Hominis, Derma- 
titis Blastomycotica. Ger. y Hefenmykose.) 

Blastomycosis of the skin in man is a disorder induced by the pres- 
ence in the skin of a vegetable organism belonging to the family of the 
yeast-plant, characterized by a slow progression from one point to 
another of the integument, the sites of invasion being for the most part 
characterized by vegetations and minute wart-like elevations of the 
surface, which may break down into ulcerations capable of producing 
grave destruction of tissue. 

The invasion of the body of animals by a blastomyces had been 
recognized and carefully studied before cases of evolution of the dis- 
ease in the human family had been determined. The dermatoses it is 
capable of producing in man have been recorded in a group of cases 
by Gilchrist, Busse, Buschke, Wells, Hessler, Hektoen, Stelwagon, 
Dyer, and others, including ourselves. 1 Of about a score of recorded 
cases occurring in man but one or two have been recognized outside of 
America. 

Symptoms. — The disease commonly begins with the production of 
a split-pea-sized papule which may later assume a pustular character, 
elevated, circular in outline, and extending slowly by multiplication 
or enlargement either in one linear or in several directions. In some 
cases the field traversed assumes permanently a verruciform aspect, 
the patch or patches being covered with raised and isolated filiform 
projections one to four millimetres in height, each capped with a crust 
formed by desiccation of sero-pus. The papillomatous character of 
the patch, with a somewhat reddened and exactly defined peripheral 
border, is strongly suggestive of verrucous tuberculosis. When fully 
developed the affected area may include the larger part of the surface 
of a limb or the greater part of the facial region. The patch of this 
size is often covered with a malodorous puriform secretion smeared over 
florid vegetations, here and there commingled with false membranes, 
and has a sharply defined and distinctly elevated ridge, more pre- 
cipitous on the side of the normal skin. In some cases ulceration pro- 
gresses between the papilliform vegetations and beneath the crusts. 
The destruction of tissue resulting may in exceptional cases be grave, 

1 Bibliography. — Anthony-Herzog, Jour. Cutan. and Gen.-Urin. Dis., January, 
1900. Brayton, Indiana Med. Jour., 1900, p. 403. Buschke, A., "Ueber Hautblasto- 
mykose," Verhandl. der VI. Deutschen Dermatol. Congress, 1898. Busse, O., " Die 
Hefen. als Krankheitserreger," Berlin, 1897. Coates, Medicine, February, 1900. 
Curtis, Annal. de l'Inst. Pasteur, 1896, p. 449. Dyer, Jour. Cutan. and Gen.-Urin. 
Dis., January, 1901. Gilchrist, T. Caspar, Duhring's Cutaneous Medicine, Part L, 
p. 156, Phila., 1895; Johns Hopkins Hosp. Rep., 1896, vol. i., pp. 269 and 291. Gil- 
christ-Stokes, Jour. Exper. Med., 1898, vol. iii., No. 1. Hessler, Bobert, Indiana 
Med. Jour., August, 1898. Hektoen, Jour. Exper. Med., vol. iv., No. 3; Jour. Amer. 
Med. Assoc, December 2, 1899. Hyde-Hektoen, Brit. Jour, of Derm., November, 1899. 
Hyde-Pvicketts, Jour. Cutan. and Gen.-Urin. Dis., January, 1 901 ; report of two cases 
and review of subject, with tabulation of all cases to date. Montgomery, Jour. Cutan. 
and Gen.-Urin. Dis., January, 1901. Montgomery-Bicketts, Ibid., same date, two 
cases. Owens-Eisendrath -Beady, Annals of Surgery, November, 1899. Stelwagon, 
Amer. Jour. Med. Sci., February, 1901. Welles, H. Gideon, "Preliminary Keport of 
a Case of Blastomycetic Dermatitis," Jour. Amer. Med. Assoc, March 26, 1898. 



PLATE XXVI, 




Blastomyeetie Dermatitis. 

(From a photograph.) 



BLASTOMYCOSIS OF THE SKIN IN MAN. 



775 



the eyelids, for example, being destroyed and other organs seriously 
implicated. 

Areas of several months' duration usually show in the centre, or in 
patches irregularly placed between the verrucous portions, an elevated, 
firm though not indurated scar- tissue varying from a sixteenth to a 
quarter of an inch in thickness. This tissue is reddish, pink, or white 
in color, and contains numerous pinhead-sized abscesses, which are 
usually deep-seated and filled with a gummy or cheesy material in 
which the blastomyces are readily demonstrable. In some cases as the 
disease advances it leaves in its wake a remarkably thinned, whitish, 
atrophic integument looking like a delicate scar. 

Fig. 95. 




Blastomycosis. 

In Busse's case, which terminated fatally, the occurrence of a blasto- 
mycotic septicemia seems to have been demonstrated. The parts chiefly 
involved in the patients whose records have been published were the 
ear, the forehead, the cheek, the brow, the temple, the eyelids, the 
nose, the lips, the neck, the scrotum, the thigh, the leg, and the dorsum 
of the fingers, of the hand, and of the wrist. In one of our cases the 
disease was limited to the lower lip, producing a tumor that resembled 
an ordinary epithelioma. The clinical histories point with clearness to 
the fact of transference of the effective germs of the disease from point 
to point by the medium of the hands. 



776 PARASITIC AFFECTIONS. 

Etiology. — The patients have sometimes a good family history : 
others have been cachectic : a few only have given an unmistakable 
history of tuberculosis in the family. None has been shown to suffer 
from syphilis. Of seventeen patients, four only were women. The 
average age of the infected was forty-three years. The essential agent 
in the production of the disease is the yeast-fungus. 

Pathology. — Histologically the lesions resemble those of verrucous 
tuberculosis or of superficial epithelioma, yet differ from both. The 
surface, on which are seen irregular masses of debris consisting of pus, 
blood- and epithelial cells, and various bacteria, is marked by irregular 
papilliform projections, between which are corresponding depressions. 
The horny layer may be destroyed or it may extend in thickened 
masses between distorted papillse. 

The rete is everywhere the seat of excessive hyperplasia, producing 
branching down-growths varying greatly in size and shape. Polymor- 
phonuclear leucocytes are scattered throughout the epithelium, both 
between and within the cells, and occur often in small collections which 
form the beginning of miliary abscesses. These abscesses are charac- 
teristic of the process, and are found in all parts of the hyperplastic 
epithelium, in places breaking through to the surface. They contain 
leucocytes, nuclear fragments, detached epithelial cells, epithelial detritus, 
red blood-corpuscles, the organisms peculiar to the disease, and in many 
cases giant-cells. The epithelial cells surrounding the abscesses are 
flattened, but appear to take no active part in the process. The epithe- 
lium is separated from the corium in most places by a distinct layer of 
columnar cells, in which mitoses are seen occasionally. The rete-cells 
in general are large and appear swollen, the prickles being very con- 
spicuous and the intercellular spaces increased. Premature cornification, 
more or less complete, occurs in scattered individual cells, in groups of 
cells, and occasionally in isolated epithelial whorls. Single giant-cells, 
surrounded by a few leucocytes, are sometimes seen in the epithelium at 
some distance from the corium. 

The corium is the seat of subacute, chronic, and occasionally of 
acute inflammatory changes. Miliary abscesses occur, especially in 
acute lesions. The infiltration consists chiefly of leucocytes, endothelial 
cells, and plasma-cells, and is sometimes very dense. The number of 
mast-cells and giant-cells varies in different cases. Tubercle-like 
nodules are found in some instances. In several cases sections showed 
numerous hyalin bodies which varied greatly in size, and occurred 
chiefly in plasma-, giant-, and new connective-tissue cells. 

The appendages of the skin apparently play but a passive part in 
the process. 

The blastomycetes are found in miliary abscesses, between the epithe- 
lial cells and in the corium, and are always surrounded by more or 
less evidence of inflammation. They are rarely found within the cells. 
The giant-cells, however, usually contain one or more of the parasites. 
The number present in the tissue varies greatly. In some cases a dozen 
or more can be seen in a single field of the microscope, while in others 
they are found with difficulty. They occur usually in pairs of unequal 
size, but also singly and in groups. They are readily seen in sections 






PLATE XXVII. 




Vertical section from a typical lesion. 

a, hyperplasia of rete ; b, abscesses in epithelium; c, infiltration of cutis, x 55. 





Budding organism in 
tissue, x 1200. 



Hanging drop, x 1200. 



BLASTOMYCOSIS OF THE SKIN. 

(From photo-micrograph) 



BLASTOMYCOSIS OF THE SKIN IN MAN 777 

stained with hematoxylin and eosin or other common stains, but methy- 
lene-blue is best for showing the different parts of the organism. The 
fungus is easily demonstrated by placing fresh or hardened sections, or 
pus, in a strong solution of potassium hydroxide, or in equal parts of 
liquor potassse and glycerin ; the organisms then appear as doubly con- 
toured, highly refractive, bodies. 

When well stained, the parasite is seen to be a round, oval, or 
slightly irregular body, having a well-defined, double-contoured, homo- 
geneous capsule, and a finely or coarsely granular protoplasm, which is 
separated from the capsule by a clear space of varying width. The 
capsule resists the prolonged action of strong alkalies and acids. The 
protoplasm often contains a clear vacuole, which varies greatly in size 
in different bodies. Mature organisms have a diameter of from 7 to 20 
H, though smaller and larger forms are seen occasionally. 

Budding forms are seen in all stages of development ; *the capsules 
and clear space are pushed out apparently by the protoplasm to form 
oval buds, which grow to about one-half the size of the mother-cell 
before separating from the latter. Organisms in pairs of unequal size 
are more common than budding forms. 

Cultures of blastomyces are recorded in nine of the cases so far 
reported, and have been obtained from the pus and from tissue. Asso- 
ciated with the blastomyces in several cases have been found various 
bacilli and cocci, none of which has been demonstrated to have any 
definite relation to the process. In two cases repeated inoculations of 
media with pus from one of the lesions gave rise to pure cultures of the 
blastomyces, showing that it was pyogenic. 

The organisms in the different cases have varied in minor details, 
and in several instances have been modified considerably by varying the 
culture-media and other conditions of growth. 

Inoculation-tests have been largely unsuccessful, but in several in- 
stances subcutaneous injection of pure cultures of the blastomyces has 
resulted in the production of a local abscess, or of an inflammatory 
granulation-tissue, from which the fungus could be recovered. The 
organisms in four cases l have been inoculated in animals with the pro- 
duction of tubercular-like nodules, or other inflammatory areas, in the 
lungs, kidneys, and other organs, from which the fungus has been recov- 
ered and cultivated. 

An effort has been made by certain Italian investigators to establish 
a relationship between blastomyces and malignant tumors, but such a 
relationship is far from being satisfactorily demonstrated. 

Diagnosis. — Blastomycosis of the skin in man is to be distin- 
guished chiefly from verrucous tuberculosis. The exact distinction 
between the two can be established only after microscopical examination 
of the tissue and pus, or by cultures and animal inoculations. In 
general the disks of lupus verrucosus as compared with patches of 
blastomycotic infection are more slow of evolution, are more often 
limited to relatively small areas, are found with greater frequency 
about the lower forearm and the ankle, and are surrounded by a more 
definitely violet-tinted halo. Other disorders to be excluded by con- 

1 Gilchrist-Stokes ; Curtis ; Hyde-Hektoen ; Montgomery-Ricketts. 



778 PARASITIC AFFECTIONS. 

sideration of their characteristic features are lupus vulgaris and other 
of the tuberculoses and paratuberculoses of the skin, the vegetating 
forms of syphilis, and protozoan infection, which, it is now believed, 
may be a variant of blastomycosis. 

The Treatment is by radical destruction of the affected part with 
the aid of the curette or by the internal administration of potassium 
iodide in full doses, a measure which has been productive in some cases 
of brilliant results. Bevan is to be credited with first employing this 
method of treatment in one of our cases. Blastomycotic. septicaemia is 
to be combated by the usual energetic measures generally employed in 
such complications. 

The Prognosis may at times be exceedingly serious. Good results 
should follow early and energetic internal and local treatment. Two 
of our cases treated with the iodide have apparently recovered com- 
pletely. 

Refractory Subcutaneous Abscesses Caused by a Sporo- 
thrix are reported in two cases by Schenck, 1 and Hektoen and Per- 
kins. 2 In both cases infection occurred on the index finger, and 
produced subcutaneous nodules and abscesses along the lymphatics of 
the arm. 



DISEASES DUE TO ANIMAL PARASITES. 

SCABIES. 

(Lat. scabere, to scratch.) 

(" The Itch." Fr., Gale : Ger., Kratze.) 






Symptoms. — Scabies is a disease of polymorphic symptoms, which 
may be viewed as an artificial eczema or dermatitis, produced by the 
invasion of the itch-mite (Fig. 96). The objective symptoms differ 
according to the extent to which the skin is primarily invaded by the 
parasite, or is secondarily injured by traumatism and severe scratching 
of its surface. 

Prominent among the objective symptoms is the cuniculus, or acarian 
furrow, an elongated gallery excavated in the epidermis by the female 
acarus soon after her impregnation by the male. The male does not 
enter the skin, but is lodged beneath the crusts or other exuviae which 
gather upon its surface. This cuniculus, or furrow, is a whitish or a 
yellowish, slightly arciform, linear lesion, with regular parallel borders 
covered with dots or specks of blackish aspect, representing faeces of 
the mite. The furrow (Fig. 97) terminates at the upper extremity by 
a vesicle, pustule, or exfoliation of the surface at the site of an infun- 
dibuliform depression ; and at the deeper extremity by a whitish and 
yellowish, shining and salient point, representing always the acarus. 
This is the most characteristic symptom of scabies. 

1 Johns Hopkins Hosp. Bull., Dec, 1898. 

2 Jour. Exper. Med., 1900, vol. v., No. 1. 



SCABIES. 



179 



The "head" of the gallery, where the parasite first entered the skin, 
is usually whitish, and is more elevated than the "tail," where the 
acarus rests after laying its dozen or more of eggs. At times the entire 
cuniculus forms an elevated ridge, rather than a thread-like depression, 
with white dots along its summit. When the roof of the vesicle at 
" the head " is torn off by scratching the effect is to produce a reddened 
spot at its site, surrounded by a whitish moat running around the 
entrance of the gallery. 

Fig. 96. 




Female acarus fecundated (ventral surface). An ovum arrived at maturity is visible within the 

body. (After Kaposi.) 



When the burrow exists it can be recognized most perfectly in the 
interdigital spaces and on the skin of the penis as a tangential line, 
running from a vesicle, papule, or pustule to a distance of from one- 
eighth of an inch to an inch. It resembles a beaded, dotted, yellowish 
or blackish thread, the color being more pronounced in comparison 
with a fresh-colored and washed skin, and less marked in contrast with 
a soiled surface ; being, in a soiled and subsequently washed integu- 
ment, most conspicuous in proportion as the small puncta have served 
to entrap particles of dirt. The cuniculus may be curved, angular, 



780 PAHASITIC AFFECTIONS. 

or tortuous ; and occasionally may be seen well-nigh completely cov- 
ered by a bulla, pustule, or vesicle extending its entire length. In 
these cases, however, the female always penetrates beyond the periph- 
eral wall of such lesion, working her gallery beyond it and more 
deeply, lest she be lifted by the exudation out of reach of the succulent 
rete where she feeds. 

Hebra points to the fact that between two parallels, one drawn 
through the nipples and another at a short distance above the knees, 
on the anterior face of the body, can be recognized the greater part of 
the eruptive lesions in every case of scabies. 

The disease is indeed one peculiar to those classes which are the 
familiars of filth and poverty, occurring among these at all ages and 
in both sexes. As a matter of accident, it may appear, though rarely, 
in individuals of high social station. It is much more common in 
Scotland, Austria, Prussia, Sweden, Norway, France, and the Orient, 
than in America. During the late Civil War it prevailed with rela- 
tive frequency among the masses of Americans associated in regiments 
with foreigners who had been but a short time in the country ; and 
steadily decreased after that time. But few cases until lately were 
seen annually in the public clinics of our large cities, though here and 
there, chiefly among newly arrived immigrants, isolated " nests " of 
the disease were discovered. The later influx of immigrants to the 
United States (notably the Columbian Exposition of ] 893), however, 
in the last few years, has again brought the disease into prominence 
by reason of its greatly increased frequency. 

In consequence of the irritation produced by the parasite and the 
traumatisms of scratching the region invaded may exhibit all the symp- 
toms of acute and chronic eczema including vesicles, pustules, wheals, 
small papules, hyperemia of the skin upon which these rest, crusts 
formed by dried serum, pus, and blood, excoriations, fissures, and, in 
cases of long standing, pigmentation of the skin where the disease 
has existed. These lesions may coexist, several appearing at the same 
time upon the skin of an affected individual ; small vesicles and pus- 
tules, with perhaps a few short cuniculi visible upon their summits ; 
excoriations ; larger and longer cuniculi interspersed between inflam- 
matory papules ; a tumid skin, evidently the seat of a mild grade of 
dermatitis ; and crusts here and there, beneath which male and young 
acari are ensconced — such is the composite picture of a typical erup- 
tion in scabies. 

It will be remembered that the acarus family find nutriment, shelter, 
and all they require on the person of the individual whose skin they 
inhabit, and there is no inducement for them to colonize at the instant 
of the first opportunity offered. The transfer of a male acarus alone, 
from one person to another, would not insure a generation of the young ; 
and the unimpregnated female could not alone do more. As for the im- 
pregnated female, Hebra, on several occasions, failed to induce scabies 
when one such female only was transferred intentionally to a sound 
skin and was seen to penetrate it. Lastly, the eggs alone would not 
suffice, for they have to be nicely planted within the epidermis in 
order to be hatched safely to maturity. In brief, only the more inti- 



SCABIES. 



781 



Fig. 97. 



mate contacts of the bed at night, and the application of nails charged 
with acari of both sexes, 
especially the young, are to 
be regarded as most effective 
for the transmission of the 
disease. This fact explains 
why nearly seven men are 
found to be affected with 
scabies to one woman. 
Women, as a rule, are more 
inclined to sleep alone, or 
with those only to whom 
they have family ties ; while 
laborers, boys, apprentices, 
and persons of that class, 
including those who are 
strangers to each other, at 
times occupy the same beds, 
especially in large cities, 
where they are often hud- 
dled together at night like 
swine. 

The female acarus may 
be recognized always at the 
terminal extremity of her 
gallery, for it is now known 
that she does not in her life- 
time leave it for any pur- 
pose, as was at one time 
taught. The intruder here 
shows as a minute, whitish, 
clearly defined dot, present- 
ing a contrast in this partic- 
ular with the blackish feces 
in the gallery behind, and 
may in a good light, by a 
person of some dexterity 
and fair eyesight, be ex- 
tracted on the point of a 
cambric needle from her 
lodging-point. It is impor- 
tant to know that this para- 
site may be recognized by 
the unaided human eye. 
Its characteristic tortoise- 
like body exhibits most of 
its anatomical peculiarities under a glass enlarging the figure but one 
hundred diameters. 

The regions affected by the eruption are the sides and roots of the 
fingers and toes ; the flexor aspects of the wrist-joints ; the feet (and 




Acarian furrow, from the lumbar region. The female 
acarus is visible at the terminal extremity of the furrow 
with ventral surface exposed, and containing a mature 
ovum: tAvo ova, next her, have been laid during the 
day : the third exhibits traces of the embryo ; the twelfth 
exhibits a mature larva (a) ; twelve empty shells are also 
seen ; between these the feces are represented by black 
points. (After Kaposi.) 



782 PARASITIC AFFECTIONS. 

especially in women, the delicate skin of the feet near the instep, 
partly dorsal, partly plantar in situation) ; the palms (especially of 
women and children) and the dorsal surfaces of the hands ; the but- 
tocks (more particularly in those who are seated in the trades and occu- 
pations of life) ; the extensor faces of the joints ; the belly ; the penis 
and scrotum in men ; the anterior folds of the axillae ; the nipples and 
breasts of women ; the elbows and knees, rather than the popliteal 
space and bend of the elbow ; and the anal region. Scabies, prurigo, 
and pruritus are alike in this, that in each the face and posterior aspect 
of the body display the fewest of any lesions visible. In general, por- 
tions of the body subjected to constant pressure by the clothing, as, for 
example, the regions pressed by the corset of the woman and the waist- 
band of the trousers in man, are sites of predilection. In other cases 
the disease is encountered in the axillae, the groins, and, as a matter of 
rare exception, over the entire surface of the body. 

The itching of scabies is occasionally severe, and has, in fact, con- 
ferred upon the disease its familiar English title, " the itch." This 
sensation is usually worse at night, when the parasite is rendered active 
by the heat of the body in bed, retained by the bed-clothing. It differs 
somewhat in different cases, being at times the cause of but little com- 
plaint. There is nothing characteristic, however, in the occurrence of 
this symptom, as equally severe pruritus accompanies eczema uncon- 
nected with parasites. 

The itching which results from the epidermic tunnelling in progress 
is often noticeably more severe than would be suggested by the moder- 
ate number of skin-lesions visible. When these lesions (puncta, vesi- 
cles, pustules, blebs, papules, resulting crusts, furrows, excoriations, 
etc.) are found upon the hands the itching becomes so great that the 
infested person scratches also the accessible parts of the skin, where 
there were originally no acari, such as the inner side of the thighs, the 
lower belly, etc., as Hebra suggests, simply because they are " handy." 
Hence it is that the picture comes to resemble that of all pruritic and 
scratched skins. 

Several artificial forms of this polymorphic affection are occasion- 
ally noted. In children the face may become diseased after contact 
with the breast of the mother or the buttocks after contact with the 
flexor aspect of the nurse's arm. Large vesicles, and even rupioid 
bullae, may result from the irritation 01 their tender skins. Again, 
in subjects predisposed to eczema for any reason the invasion of the 
parasite in one region of the body, possibly a region of preference, may 
originate an eczema in another locality whither the parasite has not 
wandered. In other cases the most aggravated forms of eruption are 
seen, usually in persons of filthy habits who have long suffered from 
the malady. Thus, extensive epidermal callosities form, filled with 
debris of dead parasites unable to find nutriment longer in the corni- 
fied rete ; or extensive greenish and blackish crusts cover colonies of 
acari which survive beneath them for generations of their race. The 
nails in such extreme cases may be involved. The so-called Scabies 
Norvegica, or "Norwegian itch," belongs to this class. Hessler 1 

J Med. News, May 13, 1893. 



SCABIES. 783 

reported a case in which the entire surface of the body was covered with 
large, thick scales, which were shed freely and were riddled with acarian 
furrows. By counting the number of parasites in a scale of a given 
size he calculated that the man had upon his person at one time not 
less than 2,000,000 mites and 7,000,000 eggs. 

As a rule, the disease does not advance to severe grades. The 
parasites having gained lodgement in the skin produce characteristic 
symptoms of the disease in the average of cases, and, though un- 
recognized and persisting for weeks, are the sources of so much 
annoyance that treatment of some sort is instituted which is apt to 
restrict extension of the malady, certainly in America, within mod- 
erate limits. Usually after lodgement is effected a week or a fortnight 
elapses before the first characteristic furrow is formed, though the 
pruritus is of earlier occurrence. The extension of the disease by the 
maturing and ravages of young acari requires a few weeks more, so 
that in the course of from two to three months the evolution of the 
malady may be considered complete. In the course of about three 
months more the disease, unchecked, may become generalized. 

Even the animal parasites elect the soil upon which they thrive, and 
indeed, after such election, thrive well or ill according to the conditions 
present. This is not only exemplified in the matter of individual sus- 
ceptibility, but in the conditions of health of an affected person. Thus, 
in puerperal and typhoid fevers and other grave states of systemic dis- 
turbance the parasites perish in the skin and the eruption disappears ; 
classical symptoms may recur in convalescence if one or more acari have 
survived with sufficient vigor to reproduce their kind. 

Etiology. — The disease is produced only by the acarus scabiei (or 
Sarcoptes Scabiei), and is thus contagious, the parasites being intro- 
duced upon the surface of one individual mediately or immediately 
from the skin of another infested man or an animal. All persons are 
supposed to be susceptible to the disease, but the difficulty of intention- 
ally transmitting it by contagion is greater than that of inducing the 
leech to fasten itself indiscriminately upon any given skin. The brief 
shaking of the hand or transient personal contacts of the daytime are 
in many cases insufficient for contagion. Few practitioners of medi- 
cine suffer after careful examination of a patient. When a patient 
affected with scabies is exhibited at the clinic he is minutely and with- 
out ill results examined by dozens of students. It is probable that 
the contacts of the night incidental to the occupation of the same bed, 
or the use of gloves and other articles of apparel containing parasites 
or their ova, are essential to transmission of the disease. 

Pathology. — The pathology of the eruption induced by the parasite 
is that of the various phases of exudation. The differences between 
scabies and all other eruptions of similar type depend, in the case of 
the former, upon the peculiarities of the exciting cause of the disease. 
In the description of this, the acarus scabiei, aid has been derived from 
the chapter devoted to this subject by Kaposi. 

The female acarus (Fig. 96), visible as a yellowish- white dot at the 
cul-de-sac of her subcutaneous gallery and removed thence on the point 
of a fine needle, is visible to the naked eye, but is best examined under 



784 PARASITIC AFFECTIONS. 

the microscope. The body is oval, with a short projecting head and a 
convex dorsum transversely corrugated, with short spinous processes 
projecting for the most part backward, a direction largely followed also 
by the eight long bristles which are most noticeable at the posterior 
extremity of the trunk. The posterior portion of the dorsum also 
exhibits a series of recurved, short, hook-like projections, arranged 
circle-wise, about the anovaginal orifice. 

The flat ventral surface exhibits eight short claws or legs, four ante- 
rior and four posterior. The former are set near the head, and are 
provided each with hairs and a long pedunculated sucker ; the latter 
are armed solely with long, straight bristles. All the eight legs have 
five articulations. The head is oval in shape, and is provided with 
four pairs of mandibles and six palpi. There are two ventral outlets ; 
and a stomach, intestines, ovaries, muscles, and even mature ova can 
be recognized internally. 

The males are smaller than the females and fewer in number. They 
differ also in this, that the posterior extremities are provided with suck- 
ers and stalks, as are the anterior extremities of the female. Situated 
between the stalks and the median line is a horseshoe-shaped mass of 
chitin ensheathing a fork-shaped penis. They are said to die in the 
course of from six to eight days after copulation. The latter survive 
from twenty to sixty days. 

The female alone, as has already been said, penetrates the epidermis. 
This act she accomplishes by inserting the head first into the tissues of 
the skin, the body disappearing afterward, and depositing behind, in 
the course of her progression downward, one or two eggs daily until 
from twenty to fifty have been laid. The eggs are oval, their longi- 
tudinal axes placed transversely to the cuniculus. In the two or three 
eggs found nearest the female only a yellowish color can be distin- 
guished ; in the third to the fifth, traces of the embryo are recogniza- 
ble ; the sixth to the ninth contain larva? ; and in the oldest the head 
and front legs can be discerned. When mature the shell of the ovum 
is ruptured, usually between the third and sixth day, and the } 7 oung 
acarus reaches the surface of the skin either by making exit at the 
original point of entry of the mother or by rupture of the roof of the 
burrow. It subsequently buries itself in the skin for a brief time while 
the process of casting its slough is completed. There are three of 
these periods of existence. Before the first period is accomplished the 
young acarus is provided with but two pairs of posterior extremities, 
two anal bristles, and ten dorsal spines. After the first period it is 
an octopod with four oval bristles and twelve dorsal spines. At the 
second period it gains two dorsal spines, and after the third it pos- 
sesses fourteen. The acarus survives but a few days when removed 
from the skin and immersed in liquids which protect it from the air, 
such as water, oil, etc. 

Transmission to man of the acarus peculiar to the horse, cat, 
sheep, rabbit, elephant, etc., may be accomplished ; but the colony 
under these circumstances rarely thrives. The same is true of the 
human acarus when transferred to the lower animals. 

Diagnosis. — The diagnosis of scabies must rest upon the recognition 



SCABIES. 785 

of its special features described above. There are no lesions peculiar 
to the disease save the cuniculi, or furrows, made by the parasites, and 
they, it will be remembered, do not appear until one or two weeks have 
elapsed after infestation. They may also be obliterated or be concealed 
by excoriations when the finger-nails plough them open, or by pustu- 
lation and subsequent crusting when the irritation induced is excessive. 

I In every well-marked case, however, cuniculi can be discovered, if not 
on the fingers, wrists, or forearms, at least on the penis, the breast near 
the nipple, or upon some other covered portion of the body. "With care 
and a little dexterity a fine cambric needle can then be forced into the 
furrow well down to and a little beyond its remote cul-de-sac, and the 
Jons et origo malorum be thence extracted and placed under the ob- 

; jective of the microscope. 

Next to the cuniculus and its inmate or inmates, the two most 
important diagnostic features of scabies are the polymorphism of the 
eruption and the sites of its most frequent occurrence. These sites 

- may be described as the most important of the two. Few skilled 

I diagnosticians would fail to entertain a suspicion of scabies in a case of 

' supposed " eczema," existing upon the fingers, wrists, and penis only, 
or upon the breast of a mother, and the face and buttocks of her infant, 

■\ or the arms of its nurse. 

At the same time it is a matter of great importance to remember 
that eczema is often attended with very severe itching ; that this sen- 

: sation may be intensely aggravated after retiring to bed at night ; that 

j eczema is often limited to the hand ; it is not rarely characterized by 
interdigital vesicles and pustules ; and is, indeed, in America very 

I much the more frequently encountered of the two diseases. The popular 
conception of scabies holds to the belief that the disease is exceedingly 
common ; that every severe itching with a cutaneous exanthem is pro- 
duced by " insects " or " worms " in the skin, and that transient casual 

I contacts are abundantly capable of transmitting the offending parasite. 
Many more cases of simple eczema are supposed to be scabies than the 

I reverse. There are few villages in this country which cannot lay claim 
to an " itch," often known by a name of local significance. Among 
these provincial titles may be counted the " prairie itch " of the West. 
These affections are, as a rule, forms of eczema quite unconnected with 
the existence of a parasite, and incurable generally by the parasiticides 
too often employed to " kill " the disease. In all such instances the 
absence of the characteristic features of scabies described above, the 
absence of a history of contagion, and the presence of that of an alter- 
nating relief and aggravation of the symptoms, will point to the char- 
acter of the malady. In the severe pruritic affections of the West and 
the Northwest of America, described in the chapter devoted to the 
several forms of pruritus, it is noticeable that the patients are often 
cleanly — those who are careful as to the hygiene of the body. Scabies 
is really a filth-disease, and is best recognized among the filthy classes. 
Of diagnostic importance is the relative rarity of scabies among other 
cutaneous affections, pruritus included, observed in the United States. 
The Statistical Committee of the American Dermatological Asso- 
ciation from July 1, 1877, to January 1, 1898, reported 318,500 cases 

50 



786 PARASITIC AFFECTIONS. 

of skin-diseases of all kinds occurring in the United States and 
Canada. Of this number, 11,560 were instances of scabies, a per- 
centage of 3.66 to the total number of affections tabulated. The influ- 
ence of temporary increase of population and the crowding together of 
persons in large centres, many of whom came from foreign countries, 
is well illustrated by the statistics of scabies in the year following the 
Columbian Exposition held in the city of Chicago. During the year 
of the fair (1893) 901 cases of scabies were reported in the United 
States. During the year 1895, however, but two years afterward, the 
total number of scabies was but 383, the proportion to all cutaneous 
disorders being 2.531. 

Treatment. — The treatment of scabies has in view the destruction 
of the parasite and the relief of the cutaneous disorder which the former 
has induced. Ordinarily these two indications are fulfilled at the same 
time. The destruction of the parasite is usually followed by relief of 
the resulting cutaneous lesions ; and the skin, freed from the burrowing 
acari, is no longer tormented by the scratching, which in extreme cases 
is not only irresistible, but is also an important element in the aggra- 
vation of the lesions. In other cases, however, the resulting eczema or 
dermatitis persists after the removal of the original cause of the disease, 
and it demands special attention. Care should always be had to avoid 
treating the delicate skin of the infant with the severer remedies effi- 
cacious upon the thicker integument of the adult. 

Sulphur, in all its forms and various combinations, has long held 
the highest esteem in the treatment of the disease. Other remedies, 
however, of acknowledged efficacy are employed with satisfactory 
results, most of them owing their usefulness to the strong odor they 
emit. Among these remedies may be named carbolic acid, petroleum, 
naphtol, the oils of cloves, cinnamon, rosemary, and mint ; tar, balsam 
of Peru, and balsam of tolu ; styrax, staphysagria, Vleminckx's solu- 
tion (heretofore described), and sapo viridis. 

Sulphur is commonly employed in the form of an ointment, 1 to 2 
drachms (4.-8.) to the ounce (30.), thoroughly rubbed, first into the 
affected patches, especially between the individual fingers (or toes), 
about the wrists, over the palm and dorsum of the hand, into the axilla?, 
about the nipples, penis, buttocks, or other invaded parts, and, finally, 
over the cutaneous surface in general, the head alone excepted. If 
no severe eczematous complications exist, the inunction is well preceded 
by a warm soap or a warm soft-soap-and-water bath ; but in the event 
of such complication the bath should be deferred as decidedly injurious 
in the inflamed condition of the skin. 

The first inunction is preferably performed at night, after which the 
patient retires to bed enveloped in woollen underclothing or wrapped in 
a blanket. It is neither wise nor necessary to induce sudation by these 
measures, for the skin is best retained in simply a greasy condition, 
unmacerated by sweat. In England it is customary to bathe on the 
ensuing morning, but it is preferable to defer the bath until the cure is 
complete, however disagreeable the condition of the integument may be 
to the sufferer. The sulphur-inunctions are thus repeated for three 
successive nights, a thorough warm water-and-soap bath being finally , 



SCABIES. 



787 



employed for the purpose of cleanliness. The clothing meantime 
should either be thoroughly disinfected with sulphur, be immersed in 
boiling water, or be subjected in a stove or furnace to a dry heat 
capable of destroying all acari and ova which may adhere to it. 

In France, the routine treatment of scabies is always preceded by a 
thorough friction for twenty minutes with soft soap, special attention 
being as usual directed to the invaded areas. This operation is at once 
followed by a bath in warm water, during which the surface is also 
thoroughly scrubbed for from thirty minutes to an hour. Lastly, the 
parasiticide is well rubbed on for fifteen minutes, the patient is redressed 
in the underclothing (disinfected during the progress of the bathing), 
and the final cleansing of the skin with water is practised within 
twenty-four hours. 

When a resulting eczema demands attention it is to be treated in 
accordance with the general principles considered in the chapter devoted 
to that subject. In this case the dusting-powders, the oleated lime-water, 
and the zinc, diachylon, and even more stimulating ointments, may be 
employed with advantage. Generally, after a vigorous course of exter- 
nal treatment with sulphur, the patient should be instructed to defer 
any further topical applications to the skin for a week or more, in order 
ito test the efficacy of the method pursued. 

Sherwell 1 finds sulphur in powder as efficacious as in ointment and 
less disagreeable. He directs the patient, after a soap-and-water bath, 
to rub gently over the body half a teaspoonful of sulphur lotum, and to 
dust the same amount between the sheets of the bed occupied at night. 
The bath, the powdering of the body and bed, and a change of clothing 
are repeated every two or three days. In the average case one week 
of such treatment is sufficient. 

One of the following formulas may be substituted for the ordinary 
sulphur ointment : 



B Sulphur, flor., 3xij ; 

Potass, subcarb., 5vj ; 

Adipis, ^ix ; 

Hardy's modification of Helmerich's ointment. 



B Styracis liq., 
Petrolei, j 
01. olivae, J 
Balsam. Peru v., 
Spts. sapon. virid., 



B Potass, sulphuret., 
Sapon. alb., 
01. oliv., 
01. thym., 



B Sulphur. su*blim., \ 
Balsam. Peruv., } 
Adipis, 



f3j; 

aa f ,^ss; 

fgijss; 
f3v; 



3v; 
3xx; 

f3iv; 
gtt. xv ; 



aa £ss ; 

1j; 



For use especially in the scabies of children. 

1 Jour. Cutan. and Gen-Urin. Dis., 1899, p. 494. 



48 

24 

270 


M. 


4 




aa 15 




10 
20 


M. 

Kaposi.] 


20 

80 

16 

1 


M. 

Jadelot.] 


aa 2 




30 

[I 


M. 

hihring.] 



788 PARASITIC AFFECTIONS. 

Hebra's modification of Wilkinson's salve, Vleminckx's solution, 
and balsam of tolu are employed for the same purpose. 
Kaposi's naphtol formula is : 

B Naphtol., 15 parts ; 

Sapon. virid., 50 parts ; 

Cret. alb. pulv., 10 parts; 

Axung., 100 parts. M. 



McCall Anderson much prefers, on account of its pleasant aroma : 

M. 



R Styracis liquid., f^j ; 30 

Adipis, ^ij ; 60 

Melt and strain. 



or Schultze's modification of Pastav's formula : 



R Styracis liquid., 
Spts. rectificat., 
01. olivEe, 

Ft. liniment. 



fgj; 


30 


f 3ij ; 


8 


f3j; 


4 



M. 



Prognosis. — Scabies is a curable disease, even after persistence for 
long periods of time. When, however, complications exist, or severe 
eczema continues after the efficient action of a parasiticide, the patient 
may experience delay before attaining complete restoration to health. 

DEMODEX FOLLICULORUM. 

(Steatozoon, ok Acarus, Folliculorum. Ger., Haarsackmilbe.) 

This parasite was discovered in 1841 by Henle. It is a microscopic 
creature in the form of an elongated and jointed worm, with head separated 
from the thorax, and eight legs, four on each side, each leg with three 
articulations, and terminating in three small hooklets. The posterior 
extremity of the body is a vermiform appendage, terminating in a 
conical point (Fig. 98). 

The demodex folliculorum is found long after birth upon the free 
surface of the integument, those parts of the skin particularly where 
the sebaceous glands are large, and on patients affected with acne or 
seborrhoea oleosa, as well as upon those free from all evidences of dis- 
ease. It is encountered also in the substance of the comedo-plug, where 
at times from five to twenty may be discovered in a single follicle. A 
demodex, which is considered to be a variety of that discovered upon 
the skin of man, infests dogs, mice, and other lower animals ; and may 
in the latter be the source of disease characterized by furuncular lesions, 
abscess, and even fatal results. None of these parasites is, however, 
known to be transmissible to man. 

It has never been demonstrated to be an etiological factor in any 
disease of the skin, though De Amicis 1 and Majocchi 2 report cases of 
pigmentation of the skin due apparently to this parasite. 

1 Giorn. Ital. delle Malattie Veneree, e della Pelle, 1898, fasic iii. ; also, Brit. Jour, 
of Derm., January, 1899. 2 Ibid. 



PULEX 1RMTANS. 



789 



PULEX PENETRANS. 

(Rhyncoprion Penetrans, Sarcopsylla Westwood, Nigua, 
Chigoe, Jigger, Sand-flea.) 

The Sand-flea is a minute, brownish-red, egg-shaped parasite 
which penetrates the skin of man and of the lower animals, including 
rats and mice. It is encountered chiefly in tropical countries, but is 
said to exist in northern latitudes, even in some of the Southern States 
of the United States. Fecundated females only attack the skin, in 
man usually about the toes or near the nails, entrance being effected 
with scarcely painful pricking sensations. In the course of from five 
to ten days a painful oedema with pustulation follows, occasionally ac- 
companied by lymphangitis or severer symptoms in the 
form of gangrenous abscesses. These sequels are said 
to result from distention of the ovary of the parasite, 
which may exceed fivefold the original dimensions of the 
insect. 

The Treatment of the disease is by extraction of the 
flea with the aid of a heated needle, whereby it is simulta- 
neously destroyed. The resulting wound may be cau- 
terized or dressed antiseptically. 



Ftg. £8. 



PULEX IRRITANS. 

The Flea which specially attacks man is a brownish- 
red insect having a laterally compressed body, an oral 
haustellum, serrated soft mandibles, a tongue sheathed 
in an inferior labium, and a pair of labial, four-jointed 
palpi. Each of the triple segments of the thorax bears 
a pair of five-jointed, double-clawed legs. The male is 
from 2 to 5 mm. in length and 1 to 2 mm. in breadth, 
the female being nearly twice that size. The female de- 
posits her eggs in any fissure, crevice, fold of garment, 
or furniture which may be accessible, from which the lar- 
vae are produced in a week. The nympha is enfolded 
in a cocoon, but only the mature insects prey upon man. 
According to Geber, the insect injects an irritating fluid 
into the skin at the moment of attack. The lesion it produces is a 
hemorrhagic punctum, followed by a transitory hypersemia and a hem- 
orrhagic exudation which may persist for a few hours. 

The central punctum, or point, distinguishes the wound produced by 
the insect from macules of simple erythema ; but care should be taken 
when fever is present to exclude the symptomatic erythemata. The 
site of the wound may become an urticarial wheal. 

Mixed cases of flea-bites with wounds produced by bugs and lice are 
often seen in the lowest classes applying for relief to public charities ; 
and the deeply pigmented skins they exhibit, often with purpuric 
lesions distributed over the lower extremities, and commingled with 
syphilitic eruptions, are in the highest degree confusing. The practi- 



Demodex follicu- 
lorum. 



790 PARASITIC AFFECTIONS. 

tioner should always be on his guard in pronouncing on these cases, 
especially if the purpuric blotches occur in the cachectic or in those suf- 
fering from other diseases than those of the skin. 

FILARIA MEDINENSIS. 

(Dracunculus Medinensis, Guinea-worm.) 

Symptoms. — The lesions due to invasion of the skin by the dra- 
cunculus Medinensis are first observed at the point where the worm is 
about to make exit, which point may be at a considerable distance from 
that where it entered, and the exit may be made after an interval of 
several weeks or months. This approach to the surface for the pur- 
pose of securing exit is accomplished only when the worm is quite 
mature. After some local sensation of tension or of itching, a pea- 
sized to small-nut-sized vesico-papule forms, superficial or subdermic 
in situation, which, after accidental or intentional rupture, gives exit 
to a clear serous fluid in which the un colored head of the worm may 
be recognized. The head, which is surrounded by a quantity of leuco- 
cytes, appears either at once or in the course of a brief time, producing 
slow and sinuous movements by alternate contractions and elongations. 
The entire worm and its young may then wholly be extruded in the 
course of a week or more ; or the head may be withdrawn and another 
swelling form at another part of the surface, the first meantime closing ; 
or, in unskilfully managed cases, the worm may be torn so that the 
head only is removed, and then a severe lymphangitis with inflammatory, 
suppurative, and even gangrenous symptoms may supervene, produc- 
ing, in fact, the train of symptoms now well recognized in connection 
with septicaemia. In some cases, however, the body may be discharged 
later than the head, after the mechanical separation of the latter, with- 
out serious consequences. The escape of embryos into the adjacent 
tissue is also regarded as a grave complication. 

The chief sites of exit are the foot — particularly the heel — the leg, 
thigh, buttocks, scrotum, hands, trunk, neck, and face. There is usu- 
ally but one worm in a single subject of the disease, but the number 
may be indefinitely large in persons exposed. 

Etiology. — The disease is produced by the ingestion of water con- 
taining the larvae of the parasite. Though denied, it seems highly 
probable that it may also obtain access by a traumatism inflicted at a 
date prior to that of invasion. The fact that nearly two-thirds of all 
cases occur in the foot is not without significance. Young filarise have 
been seen penetrating the microscopic crustacese in fresh water, the 
later ingestion of which in drinking-water is supposed to be effective 
in the production of the disease. 

The disorder due to the guinea-worm is endemic in India, Arabia, 
and Persia ; it is also found in Egypt, Africa, and portions of South 
America, but with greater rarity. 

Pathology. — The female alone invades the human body ; it is a 
filiform and uniformly cylindrical body, from one-half to one metre long 
and two or three millimetres thick. The head is convex, with a central 



PULEX IRR1TANS. 791 

oral orifice surrounded by four papilla?. It is viviparous, the embryos 
numbering millions, each embryo measuring 0.08 mm. in length and 
0.0025 mm. in thickness, with a head somewhat thicker than the body, 
no buccal orifice, and a pointed tail. In from ten to a maximum of 
fifteen months the maturity of the female which has been impregnated 
is attained, and the parasite finds its way from muscles or other 
tissues in which she has been lodged or to which she has travelled to 
the surface of the body. 

The Diagnosis (to be made in countries where the disease is 
endemic) is based upon the discovery of the worm. 

Treatment. — The usual method of treatment by the natives of the 
countries named is to secure carefully the head when it appears, and 
to tease out the worm very gently day after day until the entire body 
is extracted, securing the accessible portion by winding it about a bit 
of stick or of paper. Continuous irrigation of the wound is both recom- 
mended and practised where the disease is common. Tincture of 
asafoetida has also been employed to destroy the parasite. 

Manson, 1 who has given the subject much study, has entered a pro- 
test against winding out the guinea- worm, stating ' that at best this 
process merely shortens by a feAV days the duration of treatment in case 
the parasite is properly situated in the tissues without twists or turns, 
or if it has arrived at a stage of life when, having discharged its young, 
it is ready to come out spontaneously. If, as is often the case, the worm 
is twined and twisted among the tissues, and if she is still emitting her 
young, she will resist traction, a process which will often result in rup- 
ture. In consequence of rupture at this time myriads of young escape 
into the tissues, producing violent inflammation, which is frequently 
accompanied by secondary infection and possibly by sepsis. To de- 
termine if the worm is ready to come out spontaneously, the opening 
of the tumor may be douched for a number of minutes at a time, several 
times a day, by dripping cold water over it. When under the influence 
of this douching the worm no longer emits young careful winding out 
is not objectionable. 

The treatment Manson recommends for trial in all cases is one first 
employed by a French naval surgeon, £mily. The swelling produced 
by the worm when she approaches the skin and before she has pierced 
it is injected in several places with a solution of mercuric chloride 
(1 : 1000). This kills the worm, which may be subsequently absorbed, 
or if cut dow T n upon a day or two later her body can easily be with- 
drawn. In case the head of the worm be already protruding, the solu- 
tion may be injected directly into her body, which is easily removed the 
following day. A number of cases have been treated in this way 
successfully, and with no disagreeable results in the way of pain or 
inflammation. This method also reduces the time of treatment from 
not less than four weeks to the much shorter period of four or five 
days. 

The Prognosis is favorable, save in cases in which septicemic symp- 
toms develop as a consequence of coccogenous infection. 

1 Brit. Jour, of Derm., Feb., 1896. 



792 PARASITIC AFFECTIONS. 

CRAW-CRAW. 

(" Papulose Filarienne.") 

This rare affection was originally described in 1875 by Silva Aranjo. 
It has since been studied by Nielly, 1 O'Neill, Manson, and others. 

It occurs only on the West Coast of Africa, chiefly among the 
negroes, in whom papules, vesicles, pustules, and vesico-pustules appear 
as single, multiple, and disseminated or grouped lesions accompanied 
with severe pruritus. The scratching of the affected part is excessive, 
and the crusting at times is a prominent feature of the disorder. As a 
whole, the disease assumes an inflammatory aspect and is superficial in 
situation. The regions involved are the arms, forearms, and hands, the 
feet and legs, and several portions of the trunk. 

By removal of the crusts and erasion of the soft tissue beneath, it 
is said that in some cases the disease has been brought to an end. 
Other observers, after removal with a knife of the apex of selected 
lesions, have recognized a nematode filarial parasite, of the dimensions 
of y^-g- by -^sVg- of an inch, displaying two blackish points near its head 
which are said to distinguish it from jilaria Medinensis. The parasite 
of craw-craw is apparently related to the latter, and is supposed to 
belong to the family Anguillulidce or Anguillulce, a class of parasites 
discovered in some portions of Europe among the lower animals. 

CYSTICERCUS CELLULOSE CUTIS. 

Cysticerci have been recognized in the skin and subcutaneous tissues 
by fiokitansky, Lewin, Guttmann, SchifF, F6rr6ol, Duguet, and other 
observers. In these cases one or many oval or roundish, firm, elastic, 
cutaneous or subcutaneous, pea- to walnut-sized tumors, isolated or 
disseminated, unproductive of pain, project from the general level, and 
are enveloped by an unaltered integument. They occur upon the trunk 
and the extremities. They remain in this condition without change 
for years; and may accompany cysticerci of the brain and other por- 
tions of the body, productive of the serious disturbance of the economy 
which such invasion may determine. If the skin-tumors be opened 
and their contents examined, the parasite (which is the scolex or hydatid 
of taenia solium) will be recognized as an ampulliform sac, with a 
cephalic appendage, reentrant or projecting, and provided with four 
suckers and a coronal of hooklets. By no external characteristics could 
such tumors be distinguished from others of similar size and external 
appearance. Only in the rare cases of nervous complication could a 
suspicion arise based upon the real character of the disorder. Respect- 
ing this matter, however, the diagnostician is in no worse position than 
when called upon to recognize cysticerci of the viscera. Cysticerci of 
the liver are distinguished during life, and subsequently removed by 
operative procedures. 

The Diagnosis is from gumma, lipoma, epithelioma, and sarcoma. 
The first occurs only in the syphilitic ; the second has a peculiarly 
uneven surface and firm feeling ; the third is largely facial in situation ; 
and the last is of a malignant character and relatively rapid career. 

1 Bull, de T Acad, de M£d. de Paris, 1882, p. 395. 



LEPTUS. 793 



ECHINOCOCCUS. 

Weyl and Geber state that the parasite, echinococcus (larva or hydatid 
of the taenia echinococcus of the dog), not mentioned in dermatological 
treatises, is found in the human skin. Of 336 cases reported by 
Davaine, the parasite occurred thirty times in muscular and subcuta- 
neous tissues, more often in women than in men. The softish, fluctuat- 
ing tumors or vesicles produce a disagreeable sensation of tension, and 
they undergo fatty or other metamorphosis after the death of the encap- 
sulated parasite, that usually occurs in from one to two years. Explora- 
tion of the superficially seated fluctuating tumor, covered with unaltered 
integument, usually demonstrates its nature. 

DISTOMA HEPATICUM. 

Kuchenmeister l reports three instances in which the embryos of the 
large liver-fluke were encapsulated in subcutaneous tissue. The tumors 
were painful or painless, and occurred on the head, trunk, and extrem- 
ities. 

LEPTUS. 

(Leptus Autumnalis, Harvest-bug, Mower's Mite. 

Fr., Eouget.) 

The leptus (Figs. 100 and 101) is a minute, reddish or yellowish-red 
insect of the family Trombidce, visible to the naked eye, and found in 
summer and autumn clinging to bushes and grasses. It is found both 
in America and in Europe. It attacks man only after its accidental 
location upon the skin, where it perishes in the course of a few hours. 
In such situations, however, it induces considerable irritation, betrayed 
in erythematous, urticarial, papular, and even eczematous symptoms, 
accompanied by pruritus of various grades. The parts chiefly affected 
are the ankles, legs, arms, and feet. The mite may be seen in the skin as 
an orange-reddish or brick-reddish point, which represents often the body 
of the insect, its head being buried in the aperture of a follicle beneath. 
Examined after extraction, it is seen to have a relatively large cephalic 
extremity. It has a short, cylindrical, and conical haustellum, composed 
of fused double maxillae ; and two strong, hooked, five-jointed palpi, 
which can be rolled up. There are also two hatchet-like mandibles. 
It has a well-rounded or oval body 0.3558 mm. long and 0.32 mm. 
broad, provided with three pairs of legs. It is found upon the lower 
limbs, and also upon the scalp and every other part of the body. 
According to Duhring, children are especially liable to its encroach- 
ments. The disorder is relieved by the application of balsam of Peru 
in olive-oil, carbolated oil, spirit of camphor, or other mild stimulant 
or parasiticide. 

There are several species of leptus {leptus Americanus, leptus irri- 
tans) and other insects living on shrubs and grasses that, especially in 
the months of July and August, attack the human skin. 

1 Loc. cit. 



794 



PARASITIC AFFECTIONS. 



The Leptus Americanus (krithoptes monunguiculosus ; Fig. 99) is 
named by Weyl and Geber as the larva of a mite that annoys laborers 
in barley. It is yellowish white, oblong or oval in form, averaging 



Fig. 99. 




Leptus Americanus. 



0.022 mm. in length. There is a protrudible tubular haustellum, 
enclosed by serrated mandibles. On each side are five-jointed palpi. 
There are four pairs of feet — two on the cephalo-thorax ; two, abdom- 
inal in situation— all articulated to the epimeres. The tarsus of the 



Fig. 100. 



Fig. 101. 





Leptus. (After Kuchenmeister.) 



Rouget. 



first part terminates in hooked claws ; the others have haustellum disks 
on stems. Between the first and second pairs are swinging clubs, indi- 



cating the larval condition. 



LEPTUS. 795 

Dipterous Larvae in and beneath the Human Skin. 

There is no dipterous insect peculiar to man alone, but a number of 
cases are on record in which the ova of several species of oestrus have 
been deposited in the skin, and larvae subsequently been formed. The 
oestrus bovis, or gad-fly, in the most common of these. Usually, after 
the ova are deposited by the insect, a painful swelling occurs which 
may change from one point to another. When suppuration is induced 
the larvae can be removed by pressure upon the boil. Walter Smith, 1 
of Dublin, has described such a case in which the swelling upon the 
ankle of a girl, twelve years old, moved to the elbow, and there dis- 
charged a white grub nearly an inch in length. Birdsall 2 described a 

Fig. 102. Fig. 103. 



a 



OEstrus : a, the larva, natural size; b, Larvae removed from the body of a child, 

some of the segments seen under a lens, Of the exact size, after several days in alco- 

and showing the lines of minute projec- hoi : a, as seen from side ; b, as seen from 

tion; c and d, the terminal ends of the beneath, 
insect. (After Abraham.) 

specimen sent him from Gaboon, on the West Coast of Africa, in which 
two worms escaped from between the middle and the ring fingers of 
one hand ; another, workman having had a similar accident occur upon 
the leg. The fly the ova of which had been deposited in these two 
cases was said to attack the gorilla ; and members of a native tribe 
engaged in capturing these animals were reported as being commonly 
troubled in the same way. The worms sent to Birdsall were respec- 
tively one-fourth and one-half of an inch in length and about one- 
eighth of an inch in thickness. 

Abraham, of Dublin, also examined and reported upon a similar 
case, the specimen having been sent to the editor of the London Medi- 
cal Press and Circular, from Portsalon, Letterkenny. 

Several specimens illustrating these accidents have been sent to the 
authors. The larvae represented in Fig. 103 were removed from the 
body of an infant in Nebraska. The muscidoe (flesh, house, stable, 
dung, and other flies) have unarmed maxillae, and are unable to wound 
the uninjured skin. The pregnant female seeks, therefore, to deposit 
her ova where the larvae, equally unprovided with developed jaws, can 
most readily secure nutriment. Hence, open wounds and the tender 
skins of newborn infants when exposed in the summer season, are 
liable to become the depots of such ova. 

1 See Report of Internat. Med. Congress, Arch, of Derm., January, 1882. 

2 N. Y. Med. Eecord, March 18, 1882, p. 298. 



796 PARASITIC AFFECTIONS. 

The ova of other species of muscidce and oestridce (according to 
Geber, of the former, Lucilia Ccesar, in America ; Stomoxis Calcitrans, 
in Africa ; and Sareophila Wohlfarti, in Russia ; of the latter, Derma- 
tobia Noxalis, Cuterebra, and Hypodermd) are occasionally found in the 
skin and subcutaneous tissue. Severe cases are reported from Texas, 
in which larvae were expelled in great number from the nares after 
inhalation of chloroform. 

IXODES. 

(Wood-tick.) 

Several species of tick are recognized, such as the Rhipicephalus 
Annul atus (cattle- tick), Amblyomma Am eric anus, Ixodes Uni- 
punctatus, and Ixodes Ricinus (wood-beetle), the last named being 
more common in Europe. In America wood-ticks are found in 
wooded districts, especially where pine- and fir-trees are growing. 
The female attacks the human skin by thrusting into it her beak, 
armed on either side with a maxillo-labial projection having recurved 
hooklets, the mandibles also presenting similar obstacles to the forcible 
extraction of the head. After suction of the blood from beneath, the 
body of the tick swells to the size of that of a pea or small bean, and 
may remain for several days in this position. At such times the para- 
site may be mistaken for a small pedunculated tumor. Forcible 
attempts at extraction of the intruder are liable to detach the mandibles 
from the body, and thus leave them as the source of future irritation 
and even disagreeable inflammatory symptoms in the site of the punc- 
tured wound. On applying over the tick a drop of spirit of turpen- 
tine or benzine the head is spontaneously retracted and the body falls 
from its position. Soldiers on the plains of the United States accom- 
plish the same end with the juice of tobacco. The sensation produced 
at the moment of the insertion of the beak of the insect is said to be 
so trifling as often to pass unnoticed. 

PEDICULOSIS. 

(Lat. pediculus, a little foot.) 

(Phtheiriasis, Morbus Pediculosis, Lousiness.) 

Symptoms. — Lice belong to the order Rliynchotta ; subdivision Par- 
asites ; family, Pediculidce. They are apterous, provided each with 
two eyes, and have an oral appendage capable of both inflicting wounds 
and producing suction. The lice infesting the human body are recog- 
nized as belonging to three varieties, those of the head, of the body, 
and of the pubes. Of the disorders to which they give rise, it may be 
said in general that the lesions presented differ according to the region 
invaded, to the multiplicity of the intruders, and to the length of time 
during which their ravages have been inflicted. Such lesions, however, 
are those which have been already studied in connection with eczema, 
urticaria, and the similar disorders resulting from external irritation. 
Their special peculiarities in pediculosis are owing solely to the nature 
of the exciting cause and to the mode of its operation. 



PEDICULOSIS. 



797 



Fig. 104. 



Fig. 




Pediculosis Capillitii. 

(Parasite, the Head-louse.) 

The head-louse (Fig. 104) is usually of a grayish color, but differs 
slightly with the hue of the hair on the part which it frequents. Its 
head presents indistinctly the outline of a trefoil, 
and is provided with two hairy antennae (each of 
five articulations) and with two eyes. Its thorax is 
relatively narrow, with six tracheal stigmata and 
three hairy legs on either side, the legs being pro- 
vided with tarsal hooklets. The abdomen is di- 
vided into seven segments, defined by blackish 
indentations on either side. The males are fewer 
and smaller than the females, and they present 

upon the dorsum an ano- 

genital orifice and a large 

conoidal penis and testes. 

The females are provided Pedicuius capiiiitii-maie. 

,^ . . (Alter Ktjchenmeister.) 

with ovaries and with an 

anal aperture in the terminal abdominal seg- 
ment. Coupling is performed with the male 
beneath. 

The ova or "nits" (Fig. 105) are w T hitish 
bodies of oval contour, that are glued to the 
hairs by a cylindriform sheath of chitin which 
completely encases each filament. They are de- 
posited in series, as the female traverses the hair 
from its insertion to its distal extremity, so that 
the oldest are in general the nearest to the scalp. 
The young escape from the ova in from three 
to eight days, and arrive at maturity in from 
eighteen to twenty days. A single female, ac- 
cording to Kaposi, can lay fifty eggs in six days, 
and thus in eight weeks have a progeny of five 
thousand lice. 

Head-lice usually limit their habitat to the 
scalp, though, rarely, in elderly men with long 
hair reaching to a full beard, they may encroach 
upon the latter. They infest every portion of 
the scalp, but find the region of the greatest pro- 
tection upon the occiput. They are found upon 
children and adults of both sexes, but are best 
furnished with lodgement upon the scalps of girls 
and of women covered with long and luxuriant 
hair. The lesions observed upon a scalp thus 
inhabited vary according to the age and vigor 
of the colony. They are few or numerous, 
discrete or confluent pustules or bullae ; the surfaces are excoriated 
by scratching and oozing with serum, pus, or blood ; the crust varying 



Ova of head-louse attached 
to hair : 1, 2, 3, ova ; a, a, chi- 
tinous cylinder surrounding 
a pilary filament; b, chiti- 
nous sheath of nearly matnre 
ovum. (After Kaposi.) 



798 PARASITIC AFFECTIONS. 

in character according to the nature of the desiccated exudate and 
sebaceous matters. Often the picture presented is a conglomerate of an 
artificial eczema and seborrhoea. 

The ova, or " nits," are usually abundant upon the hairs of an 
infested head, and will scarcely escape the attention of a close obser- 
ver. They are not to be mistaken for the exfoliated, epithelial, and 
fatty plates seen in seborrhoea sicca, disseminated among the hairs and 
often perforated by hairy filaments, since the former are firmly glued in 
position and resist the bristles of the hair-brush. The peculiarly nause- 
ating odor of the louse-infested, pustule- and crust-covered scalp is not 
to be confounded with that due to favus of the same region. 

In aggravated cases the post-cervical ganglia express, by their in- 
crease in size, the degree to which the local irritation has been pushed. 
The itching is usually severe, and in cases of long persistence in chil- 
dren may produce the usual systemic symptoms of prolonged local 
irritation. Children and patients of impoverished health and with 
poor hygienic surroundings are believed to exhibit the disease in severer 
grades than others ; but this, if indeed a fact, must at least in part be 
due rather to the more favorable conditions for development and 
multiplication of the parasites that are presented in filth-accumula- 
tion and lack of cleanliness. In the public charities of large cities 
children affected with pediculosis capillitii are presented every week 
who come from the lowest social grades of the population and from the 
filthiest quarters. In these children it is not observed that the general 
health of the patients is a factor in the severity of the affection. 

The Diagnosis of pediculosis capillitii is a matter of importance 
however simple of accomplishment, since many cases of supposed 
"pustular eczema of the scalp" have vainly been treated by one 
physician with internal remedies addressed to the systemic vice 
assumed to be responsible for the disease which another has relieved 
after the discovery of a few head-lice. The hairs should always be 
raised and separated, the scalp carefully be inspected, and the presence 
of any parasites, and especially ova or " nits " fastened to the hairs, be 
ascertained. Whether the lice have preceded or followed the eczema- 
tous state (and each of these conditions may be noted) is a matter of 
minor importance. Pustules about the nares and lips, especially of 
young girls, are often significant of pediculi of the occipital region, the 
lesions being due to picking and scratching the face under an impulse 
to relieve pruritic sensations of the scalp induced by the presence there 
of lice. 

Treatment. — The indications in the treatment of pediculosis capil- 
litii are the destruction of all parasites with their ova, and the relief 
of the induced inflammatory condition of the scalp. Generally, re- 
moval of the former is followed by spontaneous disappearance of the 
latter. For the destruction of the lice the most popular remedy in 
the United States is petroleum (not kerosene), pure or with equal parts 
of balsam of Peru (which gives it an agreeable odor), poured over the 
scalp in quantity sufficient to cover it without overflow upon the brow, 
temples, and neck. It should be rubbed in with a piece of white 
(undyed) flannel, At the end of from twelve to twenty-four hours the 



PEDICULOSIS. 



799 



lice are destroyed, and the ova are rendered incapable of development. 
This treatment is followed by a thorough shampoo with tincture of green 
soap, or with toilet-soap and hot water ; after this operation the scalp 
may require a bland unguent, such as vaselin, or a small quantity of 
scented castor-oil, either pure or in combination with spirit of wine. 
Kaposi employs petroleum as a parasiticide in combination with olive- 
oil and balsam of Peru : 5 parts of the first, 2^- parts of the second, and 
1 part of the third. Cutting the hair of women and children is unnec- 
essary, as patience and gentleness with the use of the comb will dis- 
entangle the most matted masses after the lice have been destroyed. 
Other remedies are employed locally for a similar purpose, of which 
the most popular are staphysagria, 1 drachm (4.) of the powdered seeds 
to the ounce (30.) of vaselin, but especially in decoction ; tincture of 
cocculus indicus ; carbolic acid in oil or water ; sabadilla ; the ethereal 
oils ; and mercurials in ointment and solution, including the mercuric 
oleates. In cases in which but a few parasites have found their way 
to the scalp, and that recently, nothing more is requisite than careful 
use of a fine-tooth comb, scrubbing the scalp with a strongly scented 
alcoholic perfume, and final bathing with soap and hot water. 

The ova adhering firmly to the hairs can be removed by soda or 
borax lotions, alcoholic solutions, or dilute acetic acid, which are sol- 
vents for the gluey material by which the " nits " are secured in place. 

Pediculosis Corporis. 

(Pediculosis Vestimenti. Parasite, the Body-louse.) 

The parasite in this disorder inhabits exclusively the clothing worn 
next the body. In anatomical peculiarities it resembles the pediculus 
capillitii already described, being, however, larger in size, the females 
also larger than the males. The thorax is separated from the abdo- 
men, the latter being hairy, yellowish at the margins, 
and provided with eight segments. The eyes are 
black and very prominent in both sexes ; and the 
periods requisite for the maturing of the ova and 
young are those named respectively in connection 
with head-lice. In color they vary from a dirty 
white to a light-grayish hue when undistended with 
blood. In the reverse of this last-named condition 
they may be recognized as having a dull-reddish or 
a purplish color, when they are also more indolent 
in their movements. They measure from 2 to 3 mm. 
in length and 1 to 1.5 mm. in breadth. The female 
lays from seventy to eighty eggs, from which the 
young are produced in from three to eight days, and 
are capable of reproduction in a fortnight more. 

They inhabit the seams of undergarments, where 
their ova are also deposited ; but in coarse woollen 
or flannel shirts they find sufficient shelter in the 
meshes of the material of which the clothing is made ; this they leave 
temporarily, solely for the purpose of obtaining nutriment from the 



Fig. 100. 




Pediculus corporis — 
female. (After 

KtfCHENMEISTER.) 



800 PARASITIC AFFECTIONS. 



skin of their host, and hence are not recognized upon the free surface 
of the integument. Upon rapid removal of the clothing of an infested 
individual a few lice may occasionally be encountered, hastily seeking 
a place of refuge, though this is rather the exception to the rule. It 
thus may happen that a louse-bitten patient will not exhibit the source 
of his trouble to his physician after a recent and complete change of 
clothing. The greater then the importance of being able to recognize 
the clinical features of the malady in the absence of the parasite. This 
recognition is comparatively easy to one who has made himself familiar 
with the symptoms of the disorder. 

The manner in which the louse is enabled to supply itself with the 
blood of man has been studied by Swammerdam, Landois, Schjodte, 
and Tilbury Fox. The last-named author has summarized the ob- 
servations of the others, and the results he gives may briefly be de- 
scribed as follows : 

Swammerdam's original view that the louse is not provided with 
mandibles by which it can inflict a wound, but with a haustellum by 
which the blood is sucked up to the head of the parasite, is confirmed 
by Schjodte. This observer, examining the head of the louse from 
behind with reflected light, discovered that the parts of the head re- 
sembling mandibles in appearance were really situated beneath its skin. 
He applied to the integument lice which previously had been starved, 
and watched each as, with retracted limbs, arched back, and head in- 
clined obliquely downward, it repeatedly projected forward and re- 
tracted through the extreme end of its head a " small, dark, narrow 
organ," by which it was firmly held in place. A triangular blood-red 
point soon became visible in front of the eyes, rapidly and alternately 
contracting and dilating, and followed by energetic peristalsis of the 
gastro-intestinal tract. If the head then be cut off in front of the eyes, 
and the haustellum carefully be extracted, the latter can be recognized 
as a brownish protrusion, armed with terminal recurved hooks, from 
which depends a delicate membranous tube varying in length. " It 
seems that the mouth is like that in the rhyncotta generally, but differs 
in the circumstance that the labium is capable of being retracted into 
the upper part of the head, and has a fold in it when so retracted. In 
order to strengthen this part, a flat band of chitin is placed on the 
under surface ; and it is thinner in the middle in order that it may bend 
and fold a little when the skin is not extended by the lower lip. The 
latter consists of two hard lateral pieces, of which the fore-ends are 
united by a membrane, so that they form a tube, of which the internal 
covering is a continuation of the elastic membrane on the top of the 
head. Inside its orifice are a number of small hooks, which assume 
different positions according to the degree of the protrusion ; and if 
this be pushed to its highest point, they form a collar of hooks curved 
backward like barbs. The pediculus first inserts its labium into a 
sweat-pore and protrudes the lip. When the hook is securely attached 
to the parts around then the first pair of setae (the real mandibles trans- 
formed) are protruded, and these are toward the point invested by a 
membrane so as to form a closed tube, from which again is exserted a 
second pair of setae or maxillae, which form a tube and end in four 



PEDICULOSIS. 801 

small lobes placed crosswise. The whole forms a membranous tube, 
along the walls of which retiform mandibles and maxilla? are placed as 
long, narrow bands of chitin. This tube can be lengthened or shortened 
at pleasure." 

This explanation of the mode in which the louse attacks the skin is 
probably true of each of the varieties which infest the human body. 
Fox well suggests that the invaded follicle, after the withdrawal of 
the haustellum, becomes the seat of a circumscribed hemorrhage. None 
of the anatomical peculiarities described above, however, completely 
explains the characteristic pruritus of pediculosis corporis, for it can 
scarcely be questioned that it is not merely at the moment of attack or 
penetration that the suffering of the victim is greatest. The pruritic 
condition of the louse-wound persists, indeed usually attains its maxi- 
mum, after withdrawal of the pediculus, and is without doubt greater 
than that awakened by merely mechanical puncture of the epidermis. 
Anyone who will compare the skin of a louse-infested patient with that 
of one who has been subjected to the acupuncture process employed 
among the lower classes of Germans, and by them known as " baun- 
scheidtismus," can convince himself of this fact. 

The lesions seen on the skin thus invaded are proportioned, as in 
pediculosis capillitii, to the size and age of the colony of parasites. 
Excoriations, usually linear, occasionally circumscribed, varying in 
depth and length, radiate irregularly from each louse-wound, and they 
may be commingled with minute papules, transitory wheals, or, in rare, 
aggravated cases, with the typical signs of diffuse eczema. All are 
produced by scratching in order to relieve the pruritus. Crusts, often 
composed of desiccated blood, rarely of serum or pus, minute and cap- 
ping the wounded follicle, or linear and coextensive with the excoria- 
tions produced by scratching, are generally conspicuous. In older cases 
these lesions are followed by the usual sequel, pigmentation, the latter 
being a partial indication of lousiness which has long been tolerated. 

In America it is rare to note the severe and intense forms of the 
malady, resulting from long-continued neglect of the skin, that occur 
in Germany. In these cases follow : dermatitis, rupioid crusts, furun- 
cles, abscesses, carbuncles, and ulcers, resulting in serious implication 
of the skin which may persist for weeks after the clothing has been 
freed from lice, and finally leave a deep-tinted, diffuse pigmentation of 
the skin-surface, suggesting that of the negro or of the patient affected 
with Addison's disease. 

The Diagnosis is a matter of importance. Patients will visit physi- 
cians, claiming that they have suffered from a " humor of the blood/' 
who have been swallowing drugs for a long period of time, in the vain 
hope of obtaining relief, with lice, at the very moment of uttering the 
complaint, crawling over their persons. Even those of good social 
position and cleanly habits will occasionally suffer after accidental 
contacts in the tram-car or railway-carriage, the hotel, the theatre, 
or other places of public resort. There are certain points to be 
carefully noted in this connection. Excoriations over the nucha, 
about the shoulders, loins, buttocks, and external faces of the thighs, 
all visible at the same time, are highly suspicious symptoms ; as an 

51 



802 PARASITIC AFFECTIONS. 

eczema, when equally diffuse, is sure to be accompanied at some point 
by perfectly classical features ; and generalized pruritus is exceedingly 
rare, its localized varieties concerning chiefly the regions about the 
mucous outlets of the body. There is a picture highly suggestive of 
pediculosis exposed to the eye when the trunk of an infested patient 
is viewed from behind. The lesions are more discrete, more irregularly 
distributed, and more intermingled with long scratch-marks, reaching, 
for example, quite over the point of one shoulder, than in most dis- 
orders with which pediculosis vestimenti could be confounded. Here 
and there minute blood-specks tell a significant tale. When clinical 
patients exhibit syphilodermata interspersed among characteristic lesions 
of pediculosis corporis the students themselves in such cases can ordi- 
narily point out the particular symptoms referable to the separate dis- 
orders present. 

In private practice it is usually advisable, for obvious reasons, to 
secure the corpus delicti before informing the sufferer of the nature of 
his or her complaint. In the case of male patients it is well to take a 
position in the rear, and when the underclothing is drawn well up from 
the shoulders a careful scrutiny of it may be made while the applicant 
for relief supposes that attention is directed instead to his person. 

The Treatment of the disorder concerns largely the clothing. The 
latter requires immersion in boiling water, or it may be wrapped in 
paper and subjected to a temperature in an oven (160°-175° F.) 
sufficient to destroy the lice and their ova. In case of recurrence of 
the malady the clothing is to be again subjected to the same process. 
Usually the resulting irritation of the skin promptly subsides. When 
several members of one family suffer all clothing worn must be sub- 
jected to similar treatment. If the skin has been unusually tormented 
by scratching, warm alkaline baths will afford some comfort, and they 
may be followed by a bland unguent or by one of the dusting-powders. 
For immediate use, before the clothing can be rid of the intruders, a 
small cheesecloth bag containing sulphur in stick or in powder may be 
worn beneath the underclothing, or the powder may be dusted in the 
clothing and rubbed over the body ; or a parasiticide ointment may be 
ordered as recommended by Duhring, prepared by adding 2 drachms 
(8.) of freshly powdered staphysagria to the ounce (30.) of hot lard, 
strained and cooled. The surface of the skin may also be anointed with 
carbolic acid dissolved in oil or in water. 

Pediculosis Pubis. 

(Crab-louse. Parasite, the Pubic Louse. Fr., Morpion.) 

In this disorder the genital region is chiefly involved, though in 
exceptional cases all the hairy portions of the skin may be invaded, 
including the eyebrows, the eyelashes, the axillae, and the moustache 
and beard, the hairy chest, and the hairy legs of men. The body 
of the pubic louse (Fig. 107) is smaller than either of those described 
above. Its head is also attached more closely to its thorax, having a 
shape which is compared with that of a violin. The thorax is not 



PEDICULOSIS. 803 

distinctly separated from the abdomen, and of the six stout legs with 
which the louse is provided, the second and third pairs are conspicuously 
powerful and armed with relatively large hooks at the tarsal extremity. 
The resemblance of the latter to the claws of a crab has given to this 
creature the common name of " crab-louse." The lateral abdominal 
indentations are much less distinct than in the other varieties ; and 
the blackish marginal marks of body- and head-lice are here scarcely 
apparent. The abdomen is also much elongated, having a more rounded 
contour. The pubic louse is provided on its lateral borders with eight 
short conical feet, terminating in bristles. It is also distinguished from 
the others of its family by the length of its anal bristles and by the 
peculiar shield-shaped carapace which covers nearly one-half of the 
dorsum. The male is from 0.8 to 1 mm. long, and from 0.5 to 0.7 
mm. wide, being thus from 1 to 1.5 mm. smaller than the female. 

The pubic louse is much more inactive than the others, and does not 
ordinarily escape its pursuer. It buries its head deeply in a follicular 
orifice, and steadies itself in this position, where it may remain for 
some time, by grasping the adjacent hairs with its short and powerful 
claws. A moderate degree of force is required for its dislodgement 
from this favorite position, and when removed its grasp of the hair to 
which it clings is so firm that the latter usually slides for its entire 
length through the claw of the louse. Occasionally it may be found 
creeping over the skin or clinging to hairs at a distance from the skin- 
surface. The pyriform ova are smaller 
than those of the head-louse, though hav- FlG - 107 - 

ing a similar color, and are, like the lat- 
ter, attached to the hairs by a firm chiti- 
nous glue. 

Pubic lice are usually acquired during 
the contacts incidental to the sexual act ; 
are, hence, more frequently encountered 
among adults ; but may, without question, 
be transmitted mediately by occupation 
of beds and covering which have been 
used by infested persons. They are thus, 
though rarely, found in children of both 
sexes. 

The lesions induced are those produced Pe dicuins pubis. 7 (After schmarda.) 
by the wounds inflicted by the parasites 

and by constant scratching, though these are rarely severe. In a few 
cases one may see a severe eczema follow the ravages of the lice, but 
in such event the complication is chiefly owing to unnecessarily severe 
self-treatment of the disorder, patients, being often morbidly anxious 
in their efforts to rid themselves of the pests. 

The Diagnosis of pediculosis pubis is between eczema and pruritus 
genitalium. The disease last named is, in both sexes, accompanied by 
itching, and that often of intense grade ; but when this is diffuse and 
symmetrical in distribution it is not limited particularly to the hairy 
parts. Eczema of the genitals is not often produced by parasites of 
that region, and it may readily be recognized by its characteristic fea- 




804 PARASITIC AFFECTIONS. 

tures. Both disorders are often, indeed, limited to symmetrical patches 
upon the side of the scrotum or one labium. The discovery of the 
parasite, however, in pediculosis pubis is always essential, and requires 
merely careful inspection and a good light. The lice may be recognized 
either at or near the point of implantation of the hairs, which also dis- 
play ova except in very recently infested individuals. The reddish 
excrement of the parasites mingled with scratch-marks and excoriated 
papules of small size may also be observed. Patients are often made 
aware of their condition by a sensation of crawling over the parts. 
Scratching of the pubic region in adults of both sexes should awaken 
suspicion of the disorder. 

Treatment. — The disease is commonly treated by the topical appli- 
cation of mercurial ointment, which is a disagreeable and rather filthy 
medicament for this locality. The 10 per cent, oleate may be substi- 
tuted for it, or, even preferably, corrosive sublimate in solution, from 
3 to 4 grains (0.2-0.268) to the ounce (30.). Petroleum and olive-oil 
with balsam of Peru, in the proportions given above in connection 
with the subject of pediculosis capillitii, are an effective combination. 
Staphysagria, carbolic acid, cocculus indicus, or one of the other sub- 
stances used in the disorders occasioned by the animal parasites, 
may be substituted if desired. It is usually better to defer bathing 
until the remedy selected for the destruction of the lice has been ap- 
plied on several occasions, after which a warm water-and-soap ablu- 
tion will commonly end the trouble. It is needless to clip the 
pubic hairs. Should an eczematous disorder remain, it requires appro- 
priate treatment, including hot bathing and the blander lotions and 
unguents. 

Vagabonds' Disease. — This is a term given to the condition of 
the skin recognized among tramps, inmates of poorhouses, and the 
filthy and neglected in general. The skin of such persons is often 
densely indurated, harsh, dry, and deeply pigmented, in consequence 
of much scratching and a consequent hyperemia. This condition is 
produced chiefly by phtheiriasis ; but is often a resultant of the incur- 
sions of several parasites, including those of the bed and of the cloth- 
ing. It is also a consequence of persistent neglect of the bath. 

Pediculi and Acari transferred to Man from the Lower 
Animals rarely thrive in such uncongenial soil, but as a matter of 
exception they occasionally survive such transfer. Thus Goldsmith, 1 
of Vermont, reports the case of a woman affected with intense pruritus, 
who after sweating profusely observed numbers of pigeon- or hen-lice 
emerging from the sweat-pores. Megnin 2 reports similar cases under 
the title Prurigo Dermanyssique, the dermanyssus avium, or gallinoe, 
being the acarus infesting domesticated fowls. The disorder is said to 
be at times epidemic in the vicinity of aviaries and pigeon-cotes, but is 
always of trifling severity. 

1 Louisville Med. News, December 31, 1881, p. 320. 

2 Les parasites et les maladies parasitaires chez l'homme, les animaux domestiques, 
etc. Paris, 1880. 



CIMEX LECTULARIUS. 805 

CIMEX LECTULARIUS. 

(ACANTHIA LeCTULARIA, BUGS, BEDBUGS.) 

Strictly speaking, the bedbug is not a parasite of man, but finds its 
congenial habitat in the bed, bedding, and bed-covering, and the walls 
and floors of apartments occupied by persons of both sexes and all 
ages. It infests also furniture, including chairs, sofas, and the cushions 
of seats occupied in public vehicles and hotels. From the cracks, 
crevices, seams, folds, or other protected points where it has found 
lodgement, it emerges usually at night, for the purpose of securing its 
nutriment in the blood of its victims. It is a pest as ancient as the 
day in which Dioscorides wrote. 

This insect has a rusty or reddish color, this differing slightly ac- 
cording as it is or is not distended with blood. It is an apterous 
member of the order Cimicid^e. It is provided with a blunt-pointed 
head, broadly attached to the thorax; two long, slender antennae; 
and a three-jointed haustellum capable of projection and retraction 
beneath the head. There are three pairs of long, slender legs by which 
it is enabled to accomplish rapid movements. The abdomen is broad 
and flattened, and oval in shape, with nine segments. The parasite 
emits a disgusting odor, which is much more distinct when it is 
crushed. 

The wound inflicted by this bug is accomplished with or without the 
consciousness of its victim, who in the former case is made aware of a 
transitory prick or sting. Soon after, decidedly pruritic, burning, or 
stinging sensations are experienced, and the wound becomes the seat 
of an urticarial wheal. The lesion then, examined soon after the inflic- 
tion of the wound, is seen to be small pea- to bean-sized, and in the 
form of an elevated and circumscribed " button " or papulo-tubercle, 
either whitish in the centre or exhibiting there also the hyperemia 
which distinguishes its peripheral zone. After the lesion has begun to 
subside and lose its acute features, which may not occur for several 
hours if it be irritated by rubbing or scratching, a minute reddish 
I punctum may be seen marking the original site of the wound. 

The lesions are usually multiple even when but a single assailant 
has been present, the insect taking apparent delight in obtaining its 
nutriment from several distinct points upon one surface. In this way 
at times its course upon the integument may for a short distance be 
traced. In cases in which the pests are numerous, as in filthy dwell- 
ings, prisons, ships, and barracks, and when infants have been attacked, 
the resulting eruption is often greatly masked by the scratching and re- 
sulting excoriations of the skin-surface. In this way vesicles, pustules, 
crusts, purpuric blotches, and even skin-infiltrations may be found, 
instead of the rosy or light-reddish typical wheals of recent cases in 
patients with fair, clean skins. 

The Diagnosis is a matter of importance, and upon it may hang a 
professional reputation. Physicians are often consulted respecting these 
lesions by patients who believe themselves to be suffering from "hives," 
"humors," exanthemata, and even from syphilis. The insect attacks 



806 PARASITIC AFFECTIONS. 

the parts of the body to which access is easy as the patient sits or 
reclines on the back or side, including the buttocks, the thighs, the 
shoulders, the loins, and the neck, in that order of frequency, rather 
more largely than the legs, much less frequently the scalp, the face, and 
the genitalia. The eruption is not to be confounded with urticaria ab 
ingestis, which is more apt to be symmetrical in disposition. 

Treatment. — The eruption is best relieved by the topical application 
of spirit of camphor, alcohol, weak carbolated lotions, or solutions of 
boric acid, 1 drachm to the pint (5. to 500.) Untreated,, it disappears 
spontaneously when the source of the disorder is removed. The most 
effective treatment is by prophylaxis, with soap, corrosive sublimate 
solutions in alcohol, and hot water employed over all accessories of the 
dwelling-house inhabited by the insects. Once discovered to be present, 
infested furniture should be scrubbed in all its crevices with a saturated 
solution of corrosive sublimate in alcohol, and bed-clothing be immersed 
in boiling water. 

CULEX PIPIENS, Etc. 

Other insects which may persistently or only occasionally attack the 
human skin are : the mosquito and gnat (Culex Pipiens) ; midges 
(Simulia) ; bees (Apes Melliferje) ; and wasps (Vespid^). They 
produce by their bites or stings various cutaneous lesions, including 
urticarial wheals, papules, ecchymoses, and in rare cases even ecchymo- 
mata. The lesions produced by the flea are found more often on the 
legs, the neck, or other covered portions of the body. Those of the 
midge and mosquito are seen on the face, the hands, and exposed parts ; 
though, when numerous and voracious, these insects will penetrate the 
clothing for the purpose of obtaining blood. Severe eruptive lesions 
are often seen in America on the faces and extremities of infants and 
children exposed during the night to the incursions of these marauders. 
The skin-symptoms are usually treated locally by aqua ammonia? or 
spirit of camphor. 

The bodies of immigrants newly arrived during the summer season 
in America, from countries where the mosquito is either rare or does not 
exist, often present singular and even formidable evidences of the attacks 
of these insects. The skin, unaccustomed to such depredations and 
quite unprotected, will often be found greatly swollen, and of a light- 
reddish hue suggestive of erysipelas. Here and there bullae are con- 
spicuous, which add to the resemblance to the last-named disease. The 
features, in consequence of the tumefaction, vesiculation, and papulation, 
may be so swollen as to present a conspicuous deformity ; and the fore- 
arms, and even the arms, seem greatly increased in size from the same 
cause. The feet and legs also may, in the unconsciousness of sleep, be 
exposed in hot weather to the depredations of these marauders, and in 
the same way the back, the buttocks, and, rarely, even the genitalia may 
present the same signs of inflammation. The matter of chief moment 
is the correct diagnosis of such cases, as many patients seeking relief under 
such circumstances have been treated for disorders with which they 
were not affected. 



PROTOZOA AND SPOROZOA. 807 



PROTOZOA AND SPOROZOA. 

The relations sustained by some forms of protozoa to diseases of the 
skin and of other organs in man are as yet undetermined. The so-called 
psorosperms observed by a number of investigators in Darier's disease, 
carcinoma, molluscum fibrosum, Paget' s disease, herpes zoster, and 
varicella have been demonstrated clearly to be bodies produced by cell- 
transformation. It is well known, however, that the livers and other 
organs of rabbits and of some other animals often contain coccidise (a 
subclass of sporozoa), and several instances of peculiar forms of disease 
in man have been reported in which protozoa were satisfactorily demon- 
strated. Psorospermosis of internal organs of man is described by 
Osier 1 and by Blanchard. 2 

Cases of protozoan infection of the skin and other organs are re- 
ported by Wernicke, 3 Pixford and Gilchrist, Psodas, 4 and D. W. Mont- 
gomery. 5 In one case the course of the disease was chronic, and the 
cutaneous lesions were almost identical clinically and histologically with 
some of the verrucous types of tuberculosis. The patient died finally 
of a general infection which was in every way similar to a tubercular 
infection, but careful search failed to reveal tubercle-bacilli, while pro- 
tozoa were found in great numbers in lesions of the skin and of other 
organs. Successful, though not entirely satisfactory, inoculations were 
made on rabbits and dogs. The protozoa and the histology of the le- 
sions in the cases have been studied by Gilchrist, who has published 
the results of his labors in the Johns Hojikins Hospital Reports, vol. i., 
1896. This report contains also "Comparisons of Two Varieties of 
Protozoa and the Blastomyces with the so-called Parasites in Certain 
Lesions of the Skin/' with a full bibliography. 

Recent studies have shown that under certain conditions blastomyces 
multiply by sporulation. This fact removes one of the chief reasons 
for making a distinction between blastomycotic and protozoic infection 
of the skin. (Cf. Chapter on Blastomycosis.) 

1 Principles and Practice of Medicine, p. 1080, 2d edition. New York, 1895. 

2 Bouchard's Traite de Pathologie generale, tome ii., p. 682. Paris, 1896. 

3 Ann. de Circ. Med. Argent., Buenos Aires, 1890, vol. xii., p. 391. 

4 Abst. in Monatshft. f. prakt. Derm., Bd. xxvii., S. 593. 

5 Brit. Jour, of Derm., October, 1900. 



INDEX. 



ABSCESSES caused by sporothrix, 77. 
Acanthia lectularia, 805 
Acantholysis bullosa, 426 
Acanthosis nigricans, 469 
Acari from lower animals, 804 
Acarus folliculorum, 139, 788 
hordei, 794 
scabiei, 783 
Achromia, 501 

unguium, 527 
Acne, 391 

albida, 142 
artificialis, 392 
atrophica. 392, 409 
cachecticorum, 392, 590 
cancro'idale, 556 
contagious, 394 
cornee, 393 
decalvarite, 518 
diagnosis, 396 
disseminata, 393 
etiology, 395 
frontalis, 409 
hypertrophica, 392 
indurata, 392 
kelo'idienne, 520 
keratosa, 393 
necrotica, 409, 601 
papulosa, 393 
parasitica, 394 
pathology, 396 
ponctuee, 137 
prognosis, 404 
punctata, 393 
pustulosa, 393 
rodens, 409 
rosacea, 404 

diagnosis, 406 

etiology, 405 

pathology, 406 

prognosis, 409 

symptoms, 404 

treatment, 407 
rosee, 404 

scrofulosorum, 392, 599 
sebacea, 124 
sebacee cor nee, 445 

fluente, 125 
symptoms, 391 
tar, 287 
treatment, 397 
urticata, 394 
varioliform e, 409, 452 
varioliformis, 409, 601 

diagnosis, 411 

etiology, 410 



Acne varioliformis, pathology, 410 
symptoms, 409 
treatment, 411 
vulgaris, 393 
Acneiform para-tuberculoses, 603 
Acnitis, 601 

Barthelemy, 123 
Acrodynia, 187 
pathology, 188 
prognosis, 188 
treatment, 188 
Acromegaly, 497 
Actinomycosis of skin, 771 
diagnosis, 773 
etiology, 772 
pathology, 772 
prognosis, 773 
symptoms, 771 
treatment, 773 
Acute circumscribed oedema, 198 
eczema, 320 
idiopathic oedema, 198 
non-inflammatory oedema, 198 
Addison's disease, 437 
Adenoma of coil-glands, 558 
of sebaceous glands, 556 

acquired benign, 556 
congenital benign, 556 
diagnosis, 557 
etiology, 557 
malignant, 557 
pathology, 557 
symptoms, 556 
treatment, 557 
of sweat-glands, 558 
sebaceum, 556 
Adenom.es sebaces cancro'idaux, 556 
Aden ulcer, 238 
Agminate folliculitis, 740 
Ainhum, 535 
Albinism, partial, 501 
Albinismus, 502 
etiology, 502 
symptoms, 502 
Albinoes, 502 
Albugo, 527 
Aleppo evil, 237 
Alkalies, 88 
Alopecia, 507 
areata, 511 

diagnosis, 515 
etiology, 513 
false, 518 
pathology, 514 
prognosis, 517 
symptoms, 511 

809 



810 



INDEX. 



Alopecia areata, treatment, 515 

circumscripta, 511 

congenita], 507 

etiology, 510 

follicularis, 518 

furfuracea, 509 

neurotica, 514 

orbicularis, 513 

pathology, 510 

pityrodes capillitli, 509 

prematura, 508 
idiopathic, 508 
symptomatic, 509 

presenile, 508 

prognosis, 511 

senile, 508 

symptoms, 507 

treatment, 510 
Alopecies cicatrieielles innominees, 518 
Amblyomma Americanus, 796 
Ansesthsesia, 716 

Analgesic paralysis, with whitlow, 534 
Anatomy of the skin, 17 
Anderson's dusting powder, 179 
Angiokeratoma, 449 

diagnosis, 450 

etiology, 450 

pathology, 450 

prognosis, 450 

symptoms, 449 

treatment, 450 
Angioma, 563 

cavernosum, 565 

diagnosis, 566 

etiology, 565 

infective, 568 

pathology, 565 

pigmentosum et atrophicum, 572 

prognosis, 568 

serpiginosum, 568 
diagnosis, 569 
etiology, 568 
pathology, 569 
symptoms, 568 
treatment, 569 

symptoms, 563 

treatment, 566, 568 
Angiome cystique, 570 
Angiomyoma, 562 
Angio-neurotic oedema, 198 
diagnosis, 199 
symptoms, 198 
treatment, 199 
Anguillulse, 792 
Anguillulidse, 792 
Anidrosis, 118 

treatment, 118 
Animal parasites, 778 
Anomalous discoloration of skin, etc., 439 
Anthemata, 60 
Anthrax, 233 

diagnosis, 234 

etiology, 233 

pathology, 234 

prognosis, 235 

simplex, 229 



Anthrax, symptoms, 235 

treatment, 234 
Antiseptic baths, 94 
Apes melliferse, 806 
Aplasie moniliforme intermittente, 524 
Area Celsi, 511 

Johnstoni, 511 
Argyria, 438 
Arrectores pilorum, 35 
Arsenic, 86 

Arthritic purpura, 430 
Asphyxia, local, 219 
Asteatose, 136 
Asteatosis, 136 

pathology, 136 
prognosis, 137 
symptoms, 136 
treatment, 136 
Atrophia cutis, 528 

maculosa et striata, 529 
pilorum propria, 522 
senilis, 528 
unguis, 526 

treatment, 527 
Atrophoderma pigmentosum, 572 
Atrophodermia neuriticum, 531 
Atrophy of hair of beard, undescribed 
form, 522 
of skin, 528 

blanching, 531 
etiology, 530 
idiopathic, diffuse, 530 

partial, 529 
pathology, 530 
symptomatic, partial, 530 
treatment, 531 
Aussatz, 670 
Autographism, 190 
Auto-infection, 65 

BACILLOGENOUS sycosis, 240 
" Bad disorder," 614 
Baldness, 507 
Barbadoes leg, 494 
Barbers' itch, 240, 753 
Bartfinne, 241 
Beaded hairs, 524 
Bed-bugs, 805 
Bees, 806 

Beigel's disease, 526 
Biskra bouton, 237 
Blasenausschlag, 412 
Blastomycosis of skin, 774 

diagnosis, 777 

etiology, 776 

pathology, 776 

prognosis, 778 

symptoms, 774 

treatment, 777 
Blattern, 157 
Blebs, 56 
Blood-vessels, 29 
Bloody sweat, 123 
Blutschware, 226 
Boatman's ringworm, 760 
Boba, 684 



INDEX. 



811 



Boil, 226 

Bouton d'Amboine, 684 

d' Orient, 237 
Bowditch Island ringworm, 759 
"Brandy-nose," 404 
Bromhidrosis, 119 
Bromidrosis, 119 

etiology, 119 

pathology, 119 

symptoms, 119 

treatment, 120 
" Brother ulcer," 686 
Bucnemia tropica, 494 
Bug, 805 
Bulb-corpuscles, 34 

of hair, 39 
Bullae, 56 

hemorrhagica?, 430 
Bullous eruption, peculiar, 266 
Burmese ringworm, 759 
Button, Biskra, 237 

Gafsa, 237 

oriental, 237 

CACHEXIA strumipriva, 726 
thyroidea, 726 
Cachexie pachydermique, 726 
Callositas, 456 

of hands, with complications, 457 
Callosities, 456 
Calvities, 507 
Cancer of connective tissue, 709 

en cuirasse, 710 

epithelial, 697 

of extremities, 702 

of genitals, 701 

hard, 700 

of lower lips, 701 

mucous surfaces, 702 
Cancroid ulcer, 697 
Cancro'ide, 539, 697 
Canities, 505 

etiology, 506 

pathology, 506 

symptoms, 505 

treatment, 506 
" Canker rash," 152 
Caraate, 767 
Carates, 767 
Carates, 767 

diagnosis, 767 

etiology, 767 

pathology, 767 

prognosis, 767 

symptoms, 767 

treatment, 767 
Carboncle, 229 
Carbuncle, 229 
Carbunculus, 229 

diagnosis, 231 

etiology, 231 

pathology, 231 

prognosis, 233 

symptoms, 230 

treatment, 232 
Carbunkel, 229 



Carcinoma, 697 

epitheliale, 697 

laterosa, 711 

melanotic, 711 

pigmented, 711 
Cascadoe, 759 
Cathartics, 88^ 
Cativi, 767 
Causes, external, 66 

internal, 63 
Cellulome epitheliale eruplif kystique, 558 
Chalazodermia, 546 
Chancre, 616 
Chancroid, 617, 665 

diagnosis, 668 

pathology, 668 

prognosis, 670 

symptoms, 666 

treatment, 669 
Chapping, 318, 378 
Chaps, 318 
Charbon, 233 

Cheilitis glandularis aposthematosa, 362 
Cheiro-pompholyx. 269 
Cheloid, 539 

Chemical and other irritation, 68 
Chicken-pox, 165 
Chignon-fungus, 526 
Chigoe, 789 

Chilblain, necrotizing, 601 
Chilblains, 176, 206 
Chloasma, 760 

from arsenic, 438 

diagnosis, 439 

etiology, 439 

pathology, 439 

prognosis, 441 

symptoms, 436 

treatment, 440 

uterinum, 437 
Chorionitis, 488 
Chromidrose, 120 
Chromidrosis, 120 
Chromocrinia, 122 
Chronic eczema, 321 

pustular dermatitis in peripheral 
patches, 217 
Cicatrices, 59 
Cicatrix, 542 

diagnosis, 543 

etiology, 543 

hypertrophic, 540 

pathology, 543 

symptoms, 542 

treatment, 543 
Cimex lectularius, 805 
diagnosis, 805 
treatment, 805 
Circumscribed and persistent oedema, 199 
Class L, 111 

II., 147 

III., 428 

IV., 435 

V., 501 

VI., 539 

VII., 713 



812 



INDEX. 



Class VIII., 729 
Classification, 109 
Clavus, 457 

histology, 457 

treatment, 457 
Cleavage of skin, 22 
Climate, 67 
Clothing, 67 
Clou, 226 

de Biskra, 237 
Coco, 684 
Cod-liver oil, 88 
Coil, 43 

Coil-duct, cysts of, 117 
Coil-glands, 43 
" Cold abscess of skin," 585 
Cold-sores," 255 
Collodion, 101 

Colloid metamorphosis of the skin, 555 
diagnosis, 556 
etiology, 556 
pathology, 556 
treatment, 556 

milium, 555 
Collo'idome miliare, 555 
Columnar adiposse, 21 
Comedo, 137 

diagnosis, 140 

"double," 138 

etiology, 138 

pathology, 139 

prognosis, 142 

symptoms, 137 

treatment, 140 
Condyloma, 461 
Condylomata, 639 
Cones fibreux, 21 
Confluent variola, 162 
Congelatio, 206 

Congenital fibrosebaceous disease, 145 
Conglomerate folliculitis, 740 
Conglomerative pustular perifolliculitis, 
253 
etiology, 254 
pathology, 254 
treatment, 254 
Consecutive lesions, 56 
Contagious acne, 394 
Copper-nose, 404 
Cor, 457 
Corn, 457 

Come de la peau, 459 
Cornu cutaneum, 459 
etiology, 460 
pathology, 460 
prognosis, 460 
treatment, 460 
Corpuscles of Krause, 34 

of Meissner, 33 

molluscous, 454 

Pacinian, 31 

tactile, 33 

of Vater, 31 

of Wagner, 33 
Cortex of hair, 40 
Cosme's paste, 706 



Couperose, 404 
Cow-pox, 167 
Crab-louse, 802 
Craw-craw, 792 
Cretinoid oedema, 726 
Crustse, 57 
Crusts, 57 
Culex pipiens, 806 
Cute, 767 
Cuterebra, 796 
Cuticle, 25 
Cuticula, 25 
Cutis, 21 

testacea, 128 

vera, 21 
Cyanhidrosis, 121 
Cystadenomes epithelieux benins, 558 
Cyst, sebaceous, 144 
Cystic lymphangioma, 570 
Cysticercus cellulosse cutis, 792 

diagnosis, 792 
Cysts of the coil-ducts, 117 

painless dermoid, 146 

DACTYLITIS, tuberculous, 586 
Dandruff, 124 
Darier's disease, 445 
Dartre, 255 

humide, 247 
Decolorization des ongles, 527 
Defluvium capillorum, 507, 509 
Delhi boil, 237 

pathology, 238 
symptoms, 237 
treatment, 238 
Demodex folliculorum, 788 
Depilatories, 485 
Derma, 21 
Dermanyssus avium, 804 

gallinse, 804 
Dermatalgia, 714 
diagnosis, 715 
Dermatite, 200 
Dermatitis, 200 
calorica, 204 

treatment, 205 
chronic pustular, in patches, 21 
contusiformis, 181 
exfoliativa, 290, 293 
diagnosis, 292 
epidemic, 298 
etiology, 292 
infantum, 292 

prognosis, 293 
treatment, 293 
pathology, 292 
prognosis, 292 
symptoms, 291 
treatment, 292 
gangrenosa, 217 

infantum, 218 
herpetiformis, 265, 423 
diagnosis, 268 
etiology, 267 
pathology, 267 
prognosis, 269 



INDEX. 



813 



Dermatitis herpetiformis, symptoms, 265 
treatment, 268 

malignant, papillary, 708 

medicamentosa, 207 
diagnosis, 215 

papillaris capillitii, 394, 520 

repens, 387 

scarlatiniformis recidivans, 175 

seborrhoeica, 381 

traumatica, 200 

venenata, 201 

diagnosis, 203 
etiology, 201 
symptoms, 201 
treatment, 203 
Dermatobia noxalis, 796 
Dermatolysis, 546 
Dermatomycosis fnrfuracea, 760 
Dermatosclerosis, 488 
Dermatoses of the scrofulous, 599 
Dermatosis Kaposi, 572 
Desquamative scarlatinoid erythema, 175 
Development of skin, 19 
Dhabie's itch, 760 
Diabetic gangrene, 218 
Diagnosis, general, 72 

scheme of, 79 
Diet in eczema, 334 
Dipterous larvae, 795 
Discoid trichophytic erythema, 740 
Diseases due to animal parasites, 778 
Disorders of glands, 111 

of sebaceous glands, 124 

of sweat-glands, 111 
Disseminate folliculitis, 601 
Disseminated ringworm, 748 
Distoma hepaticum, 793 
Diuretics, 88 
Donda ndugu, 686 

treatment, 686 
Dondos, 502 

Dracunculus Medinensis, 790 
Drug-eruptions, 207 
Dyes, 507 
Dysidrosis, 269 

ECCHYMOMATA, 430 
Ecchymoses, 430 
Echinococcus, 793 
Ecthyma, 251 

diagnosis, 252 

etiology, 252 

gangrenous, infantile, 218 

pathology, 252 

prognosis, 253 

symptoms, 251 

treatment, 253 
Eczem, 310 
Eczema, 310 

acute, 320 

ani, 370 

of anus, 370 

aurium, 363 

barbae, 366 

of beard, 366 

of breast, 372 



Eczema capillitii, 357 

capitis, 357 

of children, 356 

craquele, 318 

crurale, 373 

crurum, 373 

diagnosis, 326 

diet in, 334 

of ears, 363 

erythematosum, 312 

etiology, 321 

exfoliativum, 313, 318 

of eyelids, 365 

of face, 359 

faciei, 359 

of feet, 375 

fissum, 318 

genitalium, 367 

of genital organs, 367 

of hands, 375 

impetiginodes, 316 

intertrigo, 318 

labiorum, 361 

lichenoides, 314 

of lips, 361 

madidans, 317 

mammae, 372 

manuum, 375 

marginatum, 320, 741 

of nails, 378 

narium, 363 

of nipple, 372 

of nostrils, 363 

palpebrarum, 365 

papulosum, 313 

parasiticum, 320 

pathology, 325 

pedum, 375 

prognosis, 355 

pustulosum, 316 

relief of pruritus in, 340 

rhagadiforme, 318 

rubrum, 317 

of scalp, 357 

sclerosum, 319 

seborrhoi'cum, 320, 381 
diagnosis, 385 
etiology, 384 
pathology, 385 
symptoms, 381 
treatment, 386 

sol are, 379 

squamosum, 313, 318 

symptoms, 313 

treatment, 333 

constitutional, 334 
local, 337 

of tropics, 371 

tuberculatum, 687 

tuberculous, 604 

of nurslings, 319 

umbilici, 373 

of umbilicus, 373 

unguium, 378 

universal, 379 

verrucosum, 312, 319 



814 



INDEX. 



Eczema, vesiculosum, 315 

Eczematoid epithelioinatosis of nipple, 708 

Eiterpusteln, 251 

Electrolysis for removal of hairs, 483 

Elephantiasis, 494 

Arabum, 494 

diagnosis, 498 

etiology, 497 

Grsecorum, 670 

lymphangiectatica, 570 

pathology, 498 

prognosis, 500 

symptoms, 495 

treatment, 499 

tuberculosa cutis, 583 
Elephant leg, 494 

Endemic degeneration of bones of foot, 768 
Endothelioma, 712 
Ephelis, 435 
Ephidrosis, 111 

tin eta, 120 
Epidemic erythema, 187 

exfoliative dermatitis, 298 
etiology, 299 

herpetic fever, 256 

skin-disease, 298 
Epidermis, 25 

Epidermolysis bullosa hereditaria, 426 
Epilation, 245 
Epithelial cancer, 697 
Epithelial krebs, 697 
Epithelioma, 697 

adenoides cysticum, 558 

contagiosum, 452 

deep, 698 

diagnosis, 703 

discoid, 697 

etiology, 702 

multiple benign cystic, 558 

papillary, 699 

pathology, 703 

prognosis, 707 

superficial, 697 

symptoms, 697 

treatment, 705 

tubercular. 698 

tubular, 736 
Epitrichial layer, 28 
Equinia, 235 

etiology, 236 

pathology, 236 

prognosis, 236 

symptoms, 235 

treatment, 236 
Erbgrind, 729 
Erectores pilorum, 35 
Eruptions, feigned, 216 
Erysipel, 220 
Erysipelas, 220 

ambulans, 221 

chronic, 222 

diagnosis, 224 

etiology, 220 

Lombardy, 186 

pathology, 223 

prognosis, 225 



Erysipelas, symptoms, 220 

treatment, 224 
Erysipele, 220 
Erysipeloid, 226 

treatment, 226 
Erythanthema syphiliticum, 638 
Erythanthemata, 60 
Erythema, 171 
ab igne, 172 
annulare, 180 
bullosum, 181 

vegetans, 418 
caloricum, 172 
circinatum, 180 

desquamative scarlatiniform, 175 
diagnosis, 173 
discoid trichophytic, 740 
epidemic, 187 
figuratura, 181 
fugax, 173 
gangrenosum, 173 
hypersemicum, 172 
induratum, 181 

scrofulosorum, 600 
intertrigo, 177 

diagnosis, 178 

etiology, 178 

symptoms, 177 

treatment, 179 
iris, 181 
lseve, 173 
leprosum, 673 
marginatum, 181 
multiforme, 180 

diagnosis, 184 

etiology, 183 

pathology, 184 

prognosis, 185 

symptoms, 180 

treatment, 185 
nodosum, 181 
nummular, 740 
papulatum, 181 
papillosum, 181 
paratrimma, 173 
pernio, 176 

diagnosis, 177 

treatment, 177 
punctatum, 175 
scarlatiniforme, 175 

diagnosis, 176 

etiology, 176 

symptoms, 175 

treatment, 176 
scarlatinoid, 175 
simplex, 172 
symptomatic, 174 
symptoms, 172 
traumaticum, 172 
treatment, 173 
tuberculatum, 181 
tuberculosum, 181 
urticatum, 181 
variolous, 157 
venenatum, 173 
vesiculosum, 181 



INDEX. 



815 



Erytheme, 172 

centrifuge, 604 

indure dies scrofuleux, 600 

infectueux, 175 

noueux, 181 
Erythrasrna, 764 

diagnosis, 766 

etiology, 765 

pathology, 765 

symptoms, 764 

treatment, 766 
Erythromelalgia, 715 
Esthiomene, 580, 640 
Etiology, general, 63 
Exanthemata, 60, 147 
Exanthematic miliary tuberculosis of skin, 

584 _ 
Excoriations, 57 
External treatment, 92 

JTfARCIN, 235 

-* Farcy, 235 
Fat-columns, 21 
Favic onychomycosis, 731 
Favus, 729 

of nails, 731 

squamosus, 730 
Feigned eruptions, 216 
Feigwarze, 639 
Fetid sweat, 119 
Fe.uerguertel, 258 
Fibres, medullated, 31 

non-medullated, 31 
Fibroid of skin, recurrent, 695 
Fibroma, 544 

diagnosis, 547 

etiology, 546 

fungoides, 687 

hard, 544 

molluscum, 544 

pathology, 540 

pendulum, 546 

prognosis, 547 

soft, 544 

symptoms, 544 

treatment, 547 
Fibromatosis tuberculosa cutis, 583 
Fibromyoma, 562 

Fibrosebaceous disease, congenital, 145 
Ficosis, 241 

Filaria Medinensis, 790 
diagnosis, 791 
etiology, 790 
pathology, 790 
prognosis, 791 
symptoms, 790 
treatment, 791 

sanguinis hominis, 497 
Filth, 68 

Finsen's phototherapy, 595 
Fischschuppenausschlag, 47 1 
Fish-skin disease, 471 
Fissures, 58 
"Flannel-rash," 383 
Fleckenmal, 467 
Flower-leaf seborrhoea, 127 



Flux, sebaceous, 124 

FoUiclis, 602 

Folliculite disseminee des parties glabres & 

tendence cicatricielle, 602 
Folliculites des scrofideux, 599 

et perifolliculites decalvantes, 518 

et perifolliculites destructives du follicule 
pileux, 518 
Folliculitis, 601 

agminate, 740 

barbae, 241 

conglomerate, 740 

decalvans, 518 

disseminate, 601 

exulcerans, 123 

and perifolliculitis, 254 

varioliformis, 409 
Foot, endemic degeneration of bones of. 768 

fungus, of India, 768 

Madura, 768 

tubercular disease of, 768 
Fragilitas crinium, 522 
Frambesia, 684 

diagnosis, 685 

etiology, 685 

prognosis, 685 

symptoms, 684 

treatment, 685 
Framosi, 684 
Freckles, 172, 435 
" Frost itch," 724 
Fungus foot of India, 768 
Furunculus, 226 

diagnosis, 228 

etiology, 227 

pathology, 228 

prognosis, 229 

symptoms, 227 

treatment, 228 

GAFSA button, 237 
Gale, 778 
Gangrene, diabetic, 218 

multiple, 218 

in infants, 218 

spontaneous, 218 

symmetrical, of extremities, 219 
Gangrenous infantile ecthyma, 218 
Gefdssmal, 563 
General diagnosis, 72 

etiology, 63 

pathology, 70, 72 

prognosis, 82 

symptomatology, 51 

therapeutics, 84 
Giant ringworm, 760 

swelling, 198 

wheals, 54, 190 
"Gibert" svrup, 661 
Glanders, 235 
Glands, coil, 43 

disorders of, 111 

meibomian, 42 

sebaceous, 41 

sebiparous, 41 

Tysonian, 42 



816 



INDEX. 



Glandulae ceruminosse, 42 
Glossy skin, 531 
Glycerin, 96 
Glycerolates, 96 
Glyceroles, 96 
Glycogelatins, 99, 348 
Glycosuric xanthoma, 554 
Gnats, 806 
Gommes scrofuleuses, 585 

scrofulo-tuberculeuses, 585 
" Goose-flesh/' 410 
Granular layer, 27 
Granuloma fungoides, 687 

innominatum, 601 

sarcomatodes, 687 
Grutum, 142 
Guinea-worm, 790 
Gummata, 637 
Gune, 759 

Gutartiges epithelioma, 558 
Gutta rosea, 404 

TTAAESACKMILBE, 788 
-*-*■ Hfematidrosis, 123 
Hsemophilia, 431 
Hair-bulb, 39 

cortex, 40 

deficiency of, 507 

dyes, 507 

follicle, 37 

medulla, 40 

nodes of, 524 

ringed, 505 

root, 39 

shaft, 40 

sheaths, 37 
Hairiness, 480 
Hairs, 36 

beaded, 524 

expansions of, 525 

fissures of, 525 

moniliform, 524 
Harlequin foetus, 474 
Harvest-bug, 793 
Hautentzundung, 200 
Hautfinne, 391 
Hauthorn, 459 
Hautrothe, 172 
Hautsclerem, 488 
Hebra's ungt. diachyl. albi, 346 
"Hedge-hog" skin, 473 
Hemiatrophia facialis, 491 
Hemizona, 258 
Hemorrhages, 428 
Hemorrhagic variola, 161 
Henle's layer, 38 
Heredity, 63 
Herpes circinatus bullosus, 266, 423 

circine, 739 

desquamans, 759 

facialis, 255 

febrilis, 255 

generalized, 256 

genitalis, 256 

gestationis, 266, 269, 423 

iris, 181, 266 



Herpes labialis, 255 
menstruation, 257 
phlyctsenoides, 266 
prseputialis, 256 
progenitalis, 256 
simplex 255 

pathology, 257 
symptoms, 255 
treatment, 257 
tonsurans, 739, 746 
desquamatij) 759 
maculosus, 289. 
zoster, 258 

diagnosis, 264 
etiology, 262 
pathology, 262 
prognosis, 265 
symptoms, 258 
treatment, 264 
Herpetiform hydroa, 423 
Herxheimer's spiral fibres, 25 
Hide-bound skin, 488 
Hidradenitis suppurativa, 123 
etiology, 124 
pathology, 124 
treatment, 124 
Hidroa, 423 
Hidrocystoma, 117 
Hirsuties, 480 
Hives, 188 
Hoariness, 505 
Honeycomb ringworm, 729 
Horn, 459 
Horny layer, 28 
Horse-pox, 394 
Hiihnerauge, 457 
Huxley's layer, 38 
Hycdom der Haul, 555 
Hyaloma, 555 

Hydradenitis destruens suppurativa, 123 
Hudradenomes eruplifs, 558 
Hydroa, 266, 423 

sestivale, 424, 425 
bulleuoc, 424 
herpetiform, 423 
puerorum, 424, 425 
vacciniforme, 424 
pathology, 425 
symptoms, 424 
treatment, 426 
vesiculeux, 181, 424 
Hydrocy stoma, 117 
diagnosis, 118 
etiology, 117 
pathology, 117 
symptoms, 117 
treatment, 118 
Hydrosadenitis disseminata suppurativa 
(Dubreuilh), 123 
suppurativa destruens, 601 
Hydrosis, 111 
Hyperesthesia, 713 
diagnosis, 715 
treatment, 715 
Hyperhidrosis, 111 
Hyperidrosis, 111 



INDEX. 



817 



Hyperidrosis, etiology, 112 

pathology, 113 

prognosis, 114 

symptoms, 111 

treatment, 113 
Hyperkeratosis excentrica, 451 

striata et follicularis, 451 
Hypertrichiasis, 480 
Hypertrichosis, 480 

etiology, 482 

neurotica, 481 

symptoms, 480 

treatment, 482 
Hypertrophic lichen planus, 307 
Hypertrophies, 435 
Hypertrophy of hair, 480 
Hyphogenous sycosis, 240, 753 
Hypoderm, 20 t 

Hypoderma, 796 

TCHTHYOL, 102 
A Ichthyose, 471 
Ichthyosis, 

congenita, 474 

cornea, 468 

diagnosis, 476 

etiology, 474 

follicularis, 445 

hystrix, 471 

linearis neuropathica, 468 

linguae, 474, 560 

nacrea, 473 

nigricans, 473 

pathology, 475 

prognosis, 477 

sebacea, 128 

serpentina, 473 

simplex, 471 

symptoms, 471 

treatment, 476 
Idiopathic multiple pigment sarcoma, 
Idrosadenitis, 60 
Idrosis, 111 
Ignes sacer, 258 
Impetigo, 247 

contagiosa, 248 
bullosa, 248 

diagnosis, 250 

eczematodes, 316 

etiology, 249 

herpetiformis, 411 
diagnosis, 412 
etiology, 412 
pathology, 412 
prognosis, 412 
symptoms, 411 
treatment, 412 

pathology, 249 

strepto-coccogenata circinata, 249 

symptoms, 247 

treatment, 250 
Incubation-periods in syphilis, 618 
Infective angioma, 568 
Inflammations, 147 
Inflammatory fungoid neoplasm, 687 
Ingesta, 65 

52 



695 



I Initial rashes, variolous, 157 
Insects, wounds by, 237 
j Instruments, 107 
Internal causes, 63 

treatment, 86 
Intertrigo, 177 
Iodine, 88 
Itch, the, 778 

barbers', 753 

Dhabie's, 760 

frost, 724 

lumbermen's, 725 

Norwegian, 782 

prairie, 725 

swamp, 725 
Itch-mite, 778 
Ittiosi, 471 
Ixodes, 796 

Americanus, 796 

bovis, 796 

marginatus, 796 

ricinus, 796 

unipunctatus, 796 

JACOB'S ULCEE, 697 
J Jigger, 789 

TfAHLHEIT, 507 
■*-*■ Kakerlaken, 502 
Kelis, 539 
Keloid, 539 

Addison's 489 
Alibert's, 539 
cicatricial, 540 
diagnosis, 541 
etiology, 541 
pathology, 541 
prognosis, 542 
symptoms, 539 
treatment, 541 
Keloid-acne, 394, 520 

treatment, 521, 
Kerato-angiona, 449 
Keratodermia palmaris et plantaris 448 
diagnosis, 449 
symptoms, 448 
treatment, 449 
Keratolysis neonatorum, 292 
Keratoma, 456 
Keratosis, 442 

follicularis, 445 

contagiosa, 450 
diagnosis, 447 , 
etiology, 446 
pathology, 447 
symptoms, 446 
treatment, 447 
pigmentosa, 462 
pilaris, 442 

diagnosis, 443 
etiology, 443 
pathology, 443 
symptoms, 442 
treatment, 444 
senilis, 445 
Kerion, 752 



818 



INDEX. 



Kerion Celsi, 752 
Kleinenflechte, 760 
Knollenkrebs, 539 
Kolbenkorperchen, 34 
Koplik's sign, 148 
Krankheiten der Franzbsen, 614 
Kratze, 778 
Kraurosis vulvae, 532 
Krithoptes rnonunguiculosus, 794 
Krustenflechte, 247 
Kuhpocken, 167 
Kupferfinne, 404 
Kupferrose, 404 

7" ADBER1E, 670 
-^ ia/*a Tokelau, 759 
Land scurvy, 432 
Langerhans' cells, 27 
Lanolin, 101 
La perleche, 766 
La peta, 759 
La rosa, 1 86 
ia rose, 220 
Lassar paste, 96, 347 
Lead-and-opium wash, 344 
Lebbra, 670 
Lentigo, 435 

etiology, 435 

pathology, 436 

symptoms, 435 

treatment, 436 
Leontiasis, 670, 672 
Lepothrix, 525 

treatment, 526 
Lepra, 271, 670 

ansesthetica, 674 

Arabum, 670 

diagnosis, 681 

etiology, 677 

fungi fera, 684 

maculosa, 673 

mutilans, 673 

pathology, 679 

prognosis, 683 

symptoms, 670 

treatment, 682 

trophoneurotica, 674 

tuberosa, 671 
Lepre, 670 

Lepromes en nappe, 672 
Leprosy, 670 

atrophic, 674 

Lombardy, 186 

nerve, 674 

nodulated, 671 

tegumentary, 671 

trophoneurotic, 674 

tuberculated, 671 
Leprous roseola, 673 
Leptus, 793 

Americanus, 794 

autumnalis, 793 
Lesions, consecutive, 56 

unclassified, 60 
Leucasmus, 501 
Leucoderma, 501, 502 



Leucoderma, acquired, 502 
complete, 502 
congenital, 502 
Leucokeratosis buccalis, 560 
diagnosis, 561 
etiology, 561 
pathology, 561 
prognosis, 562 
symptoms, 560 
treatment, 561 
Leucoma, 560 

Leucoplakia buccalis, 274, 560 
Leucoplasia, 560 
Leucoplasie, 560 
Lichen annularis, 309 
annulatus, 383 
circumscriptus, 383 
eczematodes, 313 
exudativus ruber, 300 
planus, 304 

diagnosis, 308 
etiology, 307 
hypertrophicus, 307 
pathology, 307 
prognosis, 309 
symptoms, 304 
treatment, 308 
psoriasis, 296, 300 
ruber, 300 

acuminatus, 300 
diagnosis, 303 
etiology, 302 
moniliformis, 302 
obtusus, 302 
pathology, 302 
planus, 301 
prognosis, 303 
symptoms, 300 
treatment, 303 
scrofulosorum, 599 
serpiginosus, 383 
simplex, 313 
tropicus, 379 
urticatus, 189 
Lichenification, 310 
Liodermia cum melanosi et telangiectasi, 

572 
Liquor picis alkalinus, 352 
Local asphyxia, 219 
Lombardy erysipelas, 186 

leprosy, 186 
Louse, body, 799 
crab, 802 
head, 797 
pubic, 802 
Lousiness, 796 
Lucilia Csesar, 796 
Lues venerea, 614 
Lumberman's itch, 725 
Lunula, 49 
Lupani, 684 

Lupoid sycosis, 240, 242, 519 
Lupus crustosus, 578 

demisclereux de la langue, 580 
disseminatus, 607 
of ears, 519 






INDEX. 



819 



Lupus elephantiaticus, 577 
elevatus, 577 
erythematodes, 604 
erythematosus, 604 

diagnosis, 609 

discoid form, 605 

etiology, 607 

livedo form, 607 

pathology, 608 

prognosis, 611 

symptoms, 604 

telangiectatic form, 606 

treatment, 610 
exfoliativus, 577 
of extremities, 579 
exuberans, 577 
exulcerans, 578 
of face, 578 
fibrosus, 577 
fungosus, 578 
gangrsenosus, 578 
of genital organs of women, 580 
of genital region, 579 
hypertrophicus, 577 
keloides, 578 
lymphaticus, 570 
maculosus, 576 
of mucous membranes, 580 
nodosus, 577 
non-exedens, 577, 604 
non-ulcerosus, 577 
oedematosus, 577 
papillaire verruqueux, 582 
papillosus, 577 
pernio, 602, 607 
planus, 576 
profundus, 578 
psoriasiforme, 577 
-psoriasis," 577 
rodens, 578 
rupioides, 578 
sclereux, 577, 582 
sclerosus, 577, 582 
sebaceus, 604 
serpiginosus, 578 
superficialis, 578, 604 
of trunk, 579 
tuberculatus, 577 
tumidus, 577 
vegetans, 578 
verrucosus, 582 
vulgaris, 576 
Lustseuche, 614 
Lymphadenectasia, 570 
Lymphadenie cutanee, 681 
Lymphangiectasis, 569 
Lymphangiectodes, 570 
Lymphangioma, 562, 569 
capillare varicosum, 570 
cavernosum, 570 
circumscriptum, 570 

etiology, 571 

pathology, 571 

symptoms, 570 

treatment, 571 
cystic, 570 



Lymphangioma, simple, 569 

tuberosum multiplex, 560 
Lymphangitis tuberculosa cutanea, 586 
Lymphatic vessels, 30 
Lymphodermia perniciosa, 687 
Lymph-scrotum, 496 

MACULJE, 52 
Madura foot, 768 
Majee's dad, 760 
Malabar ulcer, 238 
Mai de los pintos, 767 
Maliasmus. 235 
Malignant papillary dermatitis, 708 

pustule, 233 
Mai perforant du pied, 533 

roxo, 186 
Malum perforans pedis, 533 
Mama pian, 684 
" Mange, Texas," 725 
Marine baths, 94 
Marsden's paste, 706 
Maseru, 147 
Massering ball, 403 
Matrix of nail, 49 

of root-sheath of hair, 38 
McCall Anderson's dusting-powder, 179 

salve, 95 
Measles, 147 
Medulla of hair, 40 
Meibomian glands, 42 
Melanoderma cachecticorum, 437 

of scrofulous, 604 
Melano-sarcoma, 693 
Melanosis lenticularis progressiva, 572 
Melanotic carcinoma, 711 

sarcoma, 693 
Mentagra, 241 

parasitica, 753 
Mercury, 87 
Merkel's touch-cells, 34 
Midges, 806 
Miliaire scrofuleuse, 409 
Miliaria cystallina, 115 

rubra, 379 
Miliary fever, 116 
Milium, 142 

diagnosis, 143 

etiology, 142 

pathology, 143 

prognosis, 144 

symptoms, 142 

treatment, 143 
Mineral waters, 91 
Mitesser, 137 

Moist venereal wart, 461 
Mole, pigmentary, 467 
"Moles, white," 467 
Molluscous corpuscles, 454 
Molluscum contagiosum, 452 

epitheliale, 452 
diagnosis, 455 
etiology, 454 
pathology, 454 
prognosis, 456 
symptoms, 453 



820 



INDEX. 



Molluscum epitheliale, treatment, 456 
pendulum, 544 
sebaceum, 452 
verrucosum, 452 
Monilethrix, 524 
Moniliform hairs, 524 
Morbilli, 147 

diagnosis, 150 
pathology, 149 
prognosis, 151 
symptoms, 148 
treatment, 150 
Morbus Gallicus, 614 

maculosus Werlhoffii, 432 
pediculosis, 796 
pedis entophyticus, 678 
Morphoea, 489 
Morpion, 802 
Morvan's disease, 534 
diagnosis, 535 
etiology, 535 
pathology, 535 
symptoms, 534 
treatment, 535 
Morve, 235 
Mosquito, 806 
"Mothers' marks," 565 
Mower's mite, 793 
Mucous layer, 26 
patches, 639 
"Mulberry-marks," 565 
Multiple benign cystic epithelioma, 558 
pathology, 559 
treatment, 559 
cutaneous tumors, pruritic, 465 
gangrene of skin, 218 
Muscidse, 796 
Muscles, 35 
Muscular fibres, 35 

non-striated, 35 
striated, 35 
membranes, 36 
Mycetoma, 768 
diagnosis, 771 
etiology, 770 
pathology, 770 
symptoms, 769 
treatment, 771 
Mycosis fungoides, 687 
diagnosis, 692 
etiology, 690 
pathology, 690 
prognosis, 693 
symptoms, 687 
treatment, 692 
microsporina, 760 
Myoma, 562 
dartoic, 562 
diagnosis, 563 
simple, 562 
symptoms, 562 
telangiectodes, 562 
treatment, 563 
Myringomycosis, 766 
Myxadenitis labialis, 362 
Myxcedema, 726 



Myxoedema, diagnosis, 728 
etiology, 727 
pathology, 728 
symptoms, 726 
treatment, 728 

N^EVI pigmentosi, 481 
pilosi, 481 
Nsevoid elephantiasis, 496 
Nsevus araneus, 404, 564 

flammeus, 563 

licheno'ide, 468 

linear, 468 

lipomatodes, 467 

lupus, 5G8 

mollusciformis, 467 

nervosus, 468 

pigmentosus, 467 
pathology, 468 
treatment, 469 

pilosus, 567 

sanguineus, 563 

spilus, 467 

unius lateris, 468 

vasculosus, 563 

verrucosus, 567 

vinosus, 565 
Nail-bed, 49 

-fold, 49 

-lunula, 49 

-matrix, 49 
Nails, 48 

atrophy of, 527 

white spots of, 527 
Nojuolo, 157 
Natal sore, 237 
Necrotic granuloma, 601 
Necrotizing chilblain, 601 
Nerves, 30 
Nervous papillae, 24 
Nesselfieber, 188 
Nesselsuch, 188 
Nettle-rash, 188 
Neuralgia cutis, 714 
Neurodermatitis, 718 
Neurodermia, 718 
Neuroma, 548 
Neuropathic plica, 482 
Nevrodermite, 310 
New-growths, 539 

of skin, multiple benign tumor-li 
532 
Nigua, 789 

Nodose swellings of shafts of hairs, 424 
Nodositas crinium, 522 
Noli-me-tangere, 697 
Non-striated muscular fibres, 35 
Norwegian itch, 782 
Nummular erythema, 740 

OBJECTIVE symptoms, 51 
Occupation, 67 
Odorous emanations from skin, 47 
(Edema, acute circumscribed, 198 
idiopathic, 198 
non-inflammatory, 198 






ke, 



INDEX. 



821 



(Edema, circumscribed, 199 
neonatorum, 486 
diagnosis, 486 
etiology, 486 
pathology, 486 
prognosis, 487 
symptoms, 486 
treatment, 487 
persistent, 199 
Oehl's stratum lucidum, 27 
GEU de perdrix, 457 
GEstridse, 796 
"Ohio scratches," 725 
Onychalrophie, 526 
Onychauxis, 476 
etiology, 479 
pathology, 479 
prognosis, 479 
symptoms, 477 
treatment, 479 
Onychia, syphilitic, 478 
Onychomycosis, 478, 741 

favic, 731 
Oriental button, 237 

ulcer, 237 
Osmidrosis, 119 

PACHYDEKMATOCELE, 546 
Pachydermia, 494 

lymphangiectatica, 570 
Pacinian corpuscles, 31 
Paget's disease, 372, 708 
diagnosis, 709 
pathology, 709 
prognosis, 709 
symptoms, 708 
treatment, 709 
Painless dermoid cysts, 146 
Palmar eczema, 375 
Panaris analgesique, 534 
Panniculus adiposus, 21 

button, 237 
Papillae, nervous, 24 

vascular, 24 
Papilloma, 466 

area elevatum, 467 
neuropathicum unilaterale, 468 
neuroticum, 467 
Papulae, 53 
Papules, 53 
Papulose filarienne, 792 
Papulo-tubercles, 55 
Paresthesia, 716 
Parakeratosis scutularis, 451 

variegata, 300 
Parangi, 684, 685 

treatment, 686 
Parasitse, 796 
Parasitdre Bartfinne, 753 
Parasites, animal, 778 
Parasitic affections, 729 

diseases, 68 
Paratuberculoses, 599 

acneiform, 603 

Pars papillaris, 22 

reticularis, 22 



Pasta v's formula, 788 
Paste, Lassar's, 347 

Morris's, 348 

pencils, 101 
Pastes, 96 
Patches, mucous, 639 

scaly, 640 
Pathology, general, 72 
Peculiar skin eruption of pregnancy, 266 
Pediculi from lower animals, 804 
Pediculidae, 796 
Pediculosis, 796 

capillitii, 797 

diagnosis, 798 
treatment, 798 

corporis, 799 

diagnosis, 801 
treatment, 802 

pubis, 802 

diagnosis, 803 
treatment, 804 

vestimenti, 799 
Pediculus capitis, 797 

corporis, 799 

pubis, 803 
Pelade, 511 

Peliosis rheumatica, 430 
Pellagra, 186 

etiology, 186 

pathology, 186 

prognosis, 187 

symptoms, 186 

treatment, 187 
Pemphigus, 412 

acute, 413 

acutus benignus febrilis, 413 
contagiosus adultorum, 248 
malignus febrilis, 414 

aigu prurigineux, 266 

benignus, 415 

chronic, 414 

circinatus, 266, 415 

compose, 266 

dentinus, 414 

diagnosis, 421 

disseminatus, 414 

etiology, 419 

foliaceus, 416 

gangraenosus, 218 

haemorrhagicus, 415 

haereditarius, 417 

hystericus, 269 

malignus, 415 

neonatorum, 417 

pathology, 420 

prognosis, 423 

pruriginosus, 416, 423 

prurigineux, 266 

solitarius, 415 

symptoms, 413 

treatment, 422 

vegetans, 418 

virginum, 417 

vulgaris, 414 

of young girls, 417 
Pemphigus-like dermatitis, fatal, 266 



822 



INDEX. 



Perforating ulcer of foot, 533 
diagnosis, 534 
pathology, 534 
prognosis, 534 
symptoms, 533 
treatment, 534 
Perifolliculitis, 254 
Periodic swelling, 198 
Pernio, 176 

Peruvian wart, 684, 686 
Petaloid seborrhcea, 127 
Petechia?, 430 
Petite verole, 157 
Phagedena tropica, 238 
Phlegmona diffusa, 239 
prognosis, 240 
treatment, 240 
Phlyctense, 55 
Phlyctenular, 55 
Phototherapy, Finsen, 595 
Phtheiriasis, 796 
Phymata, 55 
Physiological crises, 65 
Physiology of skin, 17 
Pian, 684 

dartre, 684 
rubo'ide, 520 
Pick's gelatino-sublimate, 348 
salicylated soap-plaster, 351 
tragacanth varnish, 349 
Piebald skin, 501 
Piedra, 526 
Pigment, 34 
Pigmentary mole, 467 
Pili annulati, 524 
Pinta disease, 767 
Pityriasis capitis, 509 
circinata, 289 
circine et margine, 289 
maculata et circinata, 289 
rosea, 289 

diagnosis, 290 
etiology, 289 
pathology, 290 
symptoms, 289 
treatment, 290 
rosee de Gihert, 289 
rubra, 293 
aigu, 293 
diagnosis, 295 
etiology, 295 
pathology, 295 
pilaire, 296 
pilaris, 296, 300 
diagnosis, 298 
etiology, 297 
pathology, 297 
prognosis, 298 
symptoms, 296 
treatment, 298 
prognosis, 296 
symptoms, 293 
treatment, 296 
tabescentium, 128 
versicolor, 760 
Plantar eczema, 375 



Plaque muqueuse, 639 

Plaques blanches de la bouche, 560 

jaundtres des paupieres, 550 
Plaster-mulls, 100 
Plasters, 100 
Plica neuropathica, 482 

Polonica, 481 
Pocken, 157 
Pocks, the, 157 
Podelcoma, 768 
Poils accidentels, 480 
Poison-ivy, 202 
Poliosis, 505 
Poliothrix, 505 
Polyidrosis, 111 
Polypapilloma tropica, 684 
Polytrichia, 480 • 
Pomphi, 53 
Pompholyx, 269, 412 

diagnosis, 270 

pathology, 270 

symptoms, 270 

treatment, 271 
"Porcupine skin," 473 
Pore, sweat, 44 
Porokeratosis, 451 
Porrigo contagiosa, 248 

decalvans, 511 

favosa, 729 

larvalis, 248 
Poultices, 101 
Powders, 100 
Pox, horse, 394 
Prairie itch, 725 

prognosis, 726 
treatment, 726 
Precautions in management of tineae, 758 
Prickle-layer, 26 
Prickly heat, 379 
Prognosis, general, 82 
Protozoa, 807 
Prurigo, 387 

agria, 388 

dermanyssique, 804 

diagnosis, 390 

etiology, 389 

ferox, 387 

gravis, 387 

Hebrse, 387 

hyemalis, 724 

niitis, 388 

pathology, 389 

prognosis, 391 

summer, 425 

symptoms, 388 

treatment, 391 

winter, 724 
Pruritus, 717 

ani, 718 

diagnosis, 720 

etiology, 719 

genitalium, 718 

hiemalis, 718, 724 

linguae, 719 

narium, 718 

palmse et piantae, 719 



INDEX. 



823 



Pruritus, pathology, 719 

prognosis, 724 

relief of, in eczema, 340 

senile, 718 

symptoms, 717 

treatment, 719 
Pselaphagia, 713 
Pseudo-atheroma, 144 
Pseudo-pelade, 518 
Psora, 271 
Psoriasis, 271 

buccal, 560 

diagnosis, 278 

etiology, 274 

linguae, 274, 560 

pathology, 276 

prognosis, 288 

symptoms, 271 

of the tongue, 474 

treatment, 281 
Psorospermose foUiculaire vegetante, 445 
Psorospermosis, 445, 708 
Pulex irritans, 789 

penetrans, 789 
Purpura, 428 

arthritic, 430 

etiology, 433 

fulminans, 432 

hsemorrhagica, 432 

pathology, 433 

prognosis, 434 

pulicosa, 430 

rheumatica, 430 

scorbutica, 432 

simplex, 430 

symptoms, 428 

treatment, 433 

urticans, 430 

urticata, 190 
Pustulae, 55 

Pustular scrofuloderm, 603 
Pustule maligne, 233 
Pustules, 55 

from wounds of reptiles and insects, 237 

QUININE, 89 
Quinquaud's disease, 518 
Quirica, 767 

RADEZYGE, 614 
Ranvier's stratum, 27 
Rash, rose, 172 

initial varieties, 157 
Rashes, scarlet, 175 
Raynaud's disease, 219 
Reptiles, wounds by, 237 
Rete Malpighianum, 26 

Malpighii, 26 

mucosum, 26 
Rete-pegs, 23 
Rhagades, 58 
Rhinoceros skin, 473 
Rhinophyma, 405 
Rhinoscleroma, 574 

diagnosis, 575 

etiology, 574 



Rhinoscleroma, pathology, 574 

prognosis, 576 

symptoms, 574 

treatment, 575 
Rhyncotta, 796 
Rhynocoprion penetrans, 789 
Ringed eruption of extremities, 309 

hair, 505 
Pingelhaaren, 524 
Ringworm, 737 

of beard, 240, 753 

boatman's, 760 

of body, 739 

Bowditch Island, 759 

Burmese, 759 

disseminated, 748 

giant, 766 

honeycomb, 729 

of scalp, 746 

scrofulous, 604 

Tokelau, 759 

yaws, 714 
Risipola Lombarda, 186 
Rodent ulcer, 697 
Root of hair, 39 
Root-sheath, inner, 38 

outer, 38 
Rosacea, 404, 565 
Roseola scarlatiniforme, 175 

syphilitic, 623 

variolous, 157 
Rose rash, 172 
Rothe Schwindfiecht, 300 
Rotheln, 151 

symptoms, 151 

treatment, 152 
BothMeie, 293 
Rothlauf, 220 
Botzkrankheit, 235 
Pougeole, 147 
Bouget, 793 
Rubella, 153 
Rubeola, 147 
Rnmex ointment, 402 
Rupia escharotica, 218 

SACCHAROMYCOSIS hominis, 810 
Salicylated soap plaster, 351 
Salol, 89 
Salt baths, 94 
Salve muslins, 100 

pencils, 101 
Sand flea, 789 
Sarcoma cutis, 693 

diagnosis, 696 
etiology, 696 
pathology, 696 
prognosis, 697 
symptoms, 693 
treatment, 696 
idiopathic, multiple pigmented, 695 
melanotic, 693 
primary non-melanotic, 694 
Sarcomatosis generalis, 687 
Sarcophila Wohlfarti, 796 
Sarcopsylla Westwood, 789 



824 



INDEX. 



Sarcoptes scabiei, 783 
Sartian disease, 683 
Satyriasis, 670 
Savill's disease, 298 
Scabies, 778 

diagnosis, 784 

etiology, 783 

Norvegica, 782 

pathology, 783 

symptoms, 778 

treatment, 786 
Scales, 56 
Scaly patches, 640 
Scar, hypertrophic, 540 

keloid, 540 
Scarf-skin, 25 
Scarlatina, 152 

anginose, 154 

diagnosis, 156 

etiology, 155 

pathology, 155 

prognosis, 157 

septic, 154 

symptoms, 152 

toxic, 155 

treatment, 156 
Scarlatine, 152 
Scarlatiniform typhus, 155 
Scarlatinoid erythema, 175 
Scarlet fever, 152 

rash, 152, 175 
Scars, 59 
Scharlach, 152 
Scheerende flechte, 739, 746 
Scheme of diagnosis, 79 
Schleimhautpapeln, 639 
Schmeerfluss, 124 
Schonlein's disease, 430 
Schultze's plaster formula, 788 
Schuppenflechte, 271 
Schwammformige, 684 
Scirrhous cancer, 741 
Sclerema adultorum, 458 

neonatorum, 487 
etiology, 487 
pathology, 487 
symptoms, 487 
treatment, 507 
Sclereme des nouveau-nes, 487 
Scleriasis, 488 
Scleroderma, 488 

circumscribed, 489 

diagnosis, 493 

diffuse symmetrical, 488 

etiology, 491 

neonatorum, 487 

pathology, 492 

prognosis, 494 

symptoms, 488 

treatment, 493 
Sclerodermic, 488 
Scratches, Ohio, 725 
Scratching, 66 
Scrofulide erythemateuse, 604 
Scrofuloderma, 584 

verrucosum, 582 



Scrofuloma, 585 

Scrofulous melanoderma, 604 

" ringworm," 604 
Scurvy, 432 

land, 432 
Seasons, 66 
Sebaceous cyst, 144 

cystic disease, rare results of, 146 

flux, 124 

glands, 41 

disorders of, 124 
secretion of, 42- 
Sebiparous glands, 41 
Seborrhagia, 124 
Seborrhcea, 1 24 

congestiva, 604 

corporis, 383 

diagnosis, 130 

etiology, 128 

lichenoides, 383 

neonatorum, 128 

oleosa, 125 

papulosa, 383 

pathology, 129 

prognosis, 135 

sicca, 125 

squamosa, 128 

symptoms, 124 

treatment, 131 
Seborrhee, 124 

depilante, 242 
Sensory dermato-neuroses, 713 
Shaft of hair, 40 
Shampooing, 132 
Shingles, 258 
Sifilide, 614 
Sifilis, 614 
Simulia, 806 
Sirop de Gibert, 661 
Skin, anatomy, 17 

atrophy of, 528 

cleavage of, 22 

development of, 19 

hide-bound, 488 

lax, 546 

odors of, 47 

physiology of, 17 

relaxed, 546 

true, 21 
Small-pox, 157 
Smokers' patches, 274, 560 
"Snuffles " in syphilis of infants, 642 
Soaps, 94 

over-fatty, 95 
Solar light and heat, 66 
Spedalskhed, 670 
Sphaceloderma, 217 
" Spider cancer," 564 
Spiradenitis, 601 

(Unna), 123 
Spiral fibres, Herxheimer's, 25 
Spitzblattern, 165 
Spitzen warzen, 461 
Splenic fever carbuncle, 233 
Spontaneous gangrene of the skin, 218 
Sporothrix, abscesses caused by, 778 



INDEX. 



825 



Sporozoa, 807 

Spots, 52 

Spotted sickness, 767 

Squamae, 56 

Stains, 52 

St. Anthony's fire, 220 

Startin's acid mixture, 131 

Steatoma, 144 

diagnosis, 145 

pathology, 144 

prognosis, 145 

symptoms, 144 

treatment, 145 
Steatorrhea, 124 
Steatozoon folliculorum, 788 
Steorrhcea, 124 
Stili dilubiles, 101 

unguentes, 101 
Stinkender Schweiss, 119 
Stinking sweat, 119 
Stomoxis calcitrans, 796 
Stratum corneum, 28 

disjunctum, 28 

granulosum, 27 

lucidum, 27 

mucosum, 26 

subcutaneum, 20 
" Strawberry-marks," 565 
Striated muscular fibres, 35 
Strophulus albidus, 142 
Subcutaneous tissue, 20 
Subjective symptoms, 51 
Sudamen, 115 

diagnosis, 116 

etiology, 116 

pathology, 116 

symptoms, 115 

treatment, 116 
Sudatoria, 111 
Suette miliaire, 116 
Sulphur baths, 93 
Suppurative tubercular lymphangiectasis, 

586 
" Swamp itch," 725 
Sweat, 46 

bloody, 123 

fetid, 119 

stinking, 119 
Sweat-glands, adenoma of, 558 

disorders of, 111 
Sweat-pore, 44 
Sweating, greenish, 122 

phosphorescent, 122 

rosy, 122 

sickness, 116 
Swelling, " giant," 198 

periodic, 198 
Sycosiform dermatoses, 240 
Sycosis, 240 

bacillogenous, 240 

diagnosis, 244 

etiology, 243 

hyphogenous, 240, 753 

lupoid, 240, 519 

non -parasitic, 241 

parasitica, 753 



Sycosis, pathology, 243 
prognosis, 246 
staphylogenes, 241 
symptoms, 241 
treatment, 244 
vulgaris, 241 
Symmetrical gangrene of extremities, 219 
etiology, 220 
pathology, 220 
prognosis, 220 
treatment, 220 
Symptomatic erythema, 174 
Symptomatology, general, 51 
Symptoms, objective, 51 

subjective, 51 
Synanthemata, 60 
Synovial lesions of the skin, 466 
Syphilides, 619 

erythematous, 623 
palmar, 629 
pigmentary, 625 
plantar, 629 
Syphilis, 614 

diagnosis, 649 
etiology, 645 
galloping, 615 
iodine in, 660 
mercury in, 653 

fumigation, 657 
ingestion, 653 
inunction, 656 
subcutaneous injection, 658 
of mucous membrane, 639 
pathology, 640 
precocious, 615 
primary, 615 
prognosis, 665 
secondary, 614 
symptoms, 615 
tardy, 615 
tertiary, 615 
treatment, 650 
Syphilitic fever, 618 
onychia, 478 
roseola, 623 
Syphiloderma bullosum, 634 
gummatosum, 637 
infantile, 641 

acquisitum, 641 
haereditarium, 641 
maculosum, 623 

due to anomalous pigmentation, 

623 
due to hypersemia, 623 
papular, 626 

acuminate, large, 627 

small, 626 
flat, large, 628 
small, 627 
papulosum, 626 
pustular, 631 

acuminate, large, 633 

small, 632 
flat, large, 634 
small, 633 
tuberculosum, 635 



826 



INDEX. 



Syphiloderma tuberculosum serpiginosum, 
635 

vesiculosum, 631 
Syphilodermata, 619 

general characteristics, 619 
Syringo-cystadenome, 558 
Syringomyelia, 534 

ATTACHE pigmentaire, 467 
-*- Tactile corpuscles, 33 
Tan, 172 
Tar acne, 287 
baths, 94 
Taschkent-geschwur, 683 
Tattooing, 438 
Teigne faveuse, 729 

tondante, 746 
Telangiectasis, 564 

faciei, 404 
Tetia, 684 
Texas mange, 725 
Therapeutics, general, 84 
Thermal changes, 66 
Tinea barbae, 753 
circinata, 739 

diagnosis, 743 
etiology, 742 
pathology, 742 
prognosis, 746 
symptoms, 739 
treatment, 744 
decalvans, 511 
favosa, 729 

diagnosis, 534 
etiology, 731 
pathology, 732 
prognosis, 736 
symptoms, 729 
treatment, 734 
imbricata, 759 

diagnosis, 760 
etiology, 760 
pathology, 760 
prognosis, 760 
symptoms, 759 
treatment, 760 
kerion, 752 
nodosa, 526 
sycosis, 753 

prognosis, 758 
treatment, 757 
tondens, 746 
tonsurans, 746 

diagnosis, 750 
etiology, 748 
pathology, 749 
prognosis, 752 
symptoms, 746 
treatment, 751 
trichophytina, 737 
cruris, 741 
unguium, 741 
versicolor, 760 

diagnosis, 762 
etiology, 761 
pathology, 762 



Tinea versicolor, prognosis, 764 

symptoms, 760 

treatment, 763 
Toboe, 684 

Tokelau ringworm, 759 
Tono, 684 

Touch-cells (Merkel), 34 
Traumaticin, 101, 350 
Traumatism, 68 
Treatment, external, 92 

internal, 86 
Trichauxis, 480 
Trichomycosis nodosa, 525 
Trichonosis cana, 505 

versicolor, 505 
Trichophytie, 739 
sycosique, 753 
Trichophytosis barbae, 240 
Trichoptilosis, 522 
Trichorrhexis nodosa, 522 

treatment, 524 
Trombidae, 793 
True skin, 21 
Tubercles, 54 
Tuberculae, 54 

Tubercular disease of foot, 768 
Tuberculide, 601 
Tuberculosis cutis, 576 

acute, 584 

diagnosis, 591 

etiology, 581 

exanthematic miliary, 584 

orificialis, 583 

pathology, 588 

prognosis, 598 

serpiginosa ulcerativa, 586 

symptoms, 576 

treatment, 593 

verrucosa, 581, 582 
fungosa cutis, 583 
papilloraatosa cutis, 582 
suppurativa et bullosa acuta, 603 
" Tuberculous dactylitis," 586 
eczema, 604 

of nurslings, 319 
Tuberose carcinoma, 711 
Tumor cavernosus, 565 
Tumores, 55 
Tyloma, 456 
Tylosis, 456 

linguae, 560 
Tysonian glands, 42 

ULCER, Aden, 238 
"brother," 686 

cancroid, 697 

Jacob's, 697 

Malabar, 238 

oriental 237 

rodent, 697 
" Ulcer that clings," 686 
Ulcera, 58 
Ulcers, 58 
Ulcus exedens, 697 

grave, 768 
Ulerythema acneiforme, 394 



INDEX. 



827 



Ulerythema aphryogenes, 521 

centrifuguni, 604 

sycosiforme, 240, 242, 519 
Unclassified lesions, 60 
Unguentum diachyli albi, 346 
Unna's refrigerant ointment, 347 
Urticae, 53 
Urticaire, 188 
Urticaria, 188 

annularis, 189 

bullosa, 189 

diagnosis, 192 

etiology, 190 

evanida, 190 

figurata, 189 

hemorrhagica, 190 

papulosa, 189 

pathology, 192 

perstans, 190 

pigmentosa, 196 
diagnosis, 198 
etiology, 197 
pathology, 197 
symptoms, 196 
treatment, 198 

prognosis, 196 

symptoms, 188 

treatment, 193 

tuberosa, 190 

vesiculosa, 189 

TTACCINAT10N, 167 
' Vaccine, 167 
Vaccinia, 167 

generalized, 170 

pathology, 170 

treatment, 170 
Vaccinial eruptive fever, 170 
Vagabond's disease, 804 
Varicella, 165 

diagnosis, 166 

gangrenosa, 218 

pathology, 166 

symptoms, 165 
Variola, 157 

confluent, 162 

diagnosis, 163 

etiology, 162 

hemorrhagic, 161 

pathology, 163 

prognosis, 163 

symptoms, 157 

treatment, 164 
Variolette, 165 
Varioloid, 160 
Variolous erythema, 157 

roseola, 157 
Varix lymphaticns, 496 
Varnishes, 99 
Varus, 391 
Vascular papillae, 24 
Vasogen, 101 
Venereal wart, 461 

Verbunden mit Kolloider Degeneration, 558 
Vergetures, 529 
Verole, 614 



Verruca, 460 

acquisita, 461 

acuminata, 461 

congenita, 461 

diagnosis, 463 

dorsi manus et pedis, 462 

etiology, 462 

filiformis, 462 

glabra, 462 

necrogenica, 462, 581 

pathology, 463 

plana, 462 

prognosis, 465 

senilis, 462 

symptoms, 460 

treatment, 463 

vulgaris, 462 
Verrue, 460 

Verruga Peruana, 686 
Vesicles, 55 
Vesico-pustules, 56 
Vesiculae, 55 
Vespide, 806 
Vessels, blood-, 29 

lymphatic, 30 
Vibices, 430 

Visceral causes of disease, 65 
Vitiligo, 502 

diagnosis, 503 

etiology, 503 

pathology, 503 

prognosis, 505 

symptoms, 502 

treatment, 503 
Vitiligoidea, 550 

WARREN'S fat columns, 21 
Wart, 460 

cures, 465 
moist, 461 
venereal, 461 

Warze, 460 

Wasps, 806 

Wasserpocken, 165 

Water, 89, 92 

Wen, 144 

Wheals, 53 

" White moles," 467 

Wilkinson's salve, 287 

Winter prurigo, 724 

Worm, Guinea-, 790 

XANTHELASMA, 550 
Xanthelasmoidea, 196 
Xanthoma, 550 

diabeticorum, 554 
diagnosis, 555 
etiology, 554 
pathology, 554 
prognosis, 555 
symptoms, 554 
treatment, 555 
etiology, 552 
glycosuric, 554 
multiplex, 550 
palpebrarum, 550 



828 



INDEX. 



Xanthoma papulatum, 550 

pathology, 552 

planum, 550 

prognosis, 554 

symptoms, 570 

treatment, 553 

tuberculatum, 550 

tuberosum, 550 
Xeroderma, 470, 471 

pigmentosum, 572 
diagnosis, 573 
etiology, 573 
pathology, 573 
prognosis, 574 
symptoms, 572 
treatment, 572 
Xerosis, 470 

prognosis, 471 

symptoms, 470 



Xerosis, treatment, 471 
X-ray dermatitis, 66 



Y 



AWS, 684 
caeca, 684 



ZONA, 258 
Zoster, 258 

abdominalis, 261 
brachialis, 261 
capillitii, 260 _ 
collaris, 261 
facialis, 261 
femoralis, 261 
frontalis, 260 
nuchse, 261 
ophthalmicus, 260 
pectoralis, 261 

















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